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A  MANUAL  OF  SURGERY 
STEWART 


A  MANUAL  OF  SURGERY 


FOR  STUDENTS  AND  PHYSICIANS 


BY 


FRANCIS  T.  STEWART,  M.  D. 

FORMERLY  PROFESSOR   OF   CLINICAL   SURGERY,   JEFFERSON  MEDICAL  COLLEGE; 
SURGEON  TO  THE  PENNSYLVANIA  HOSPITAL 


FIFTH  EDITION 


WITH  590  ILLUSTRATIONS 


PHILADELPHIA 

P.   BLAKISTON'S   SON   &   CO 

1012   WALNUT   STREET 


Copyright,  1921,  by  P.  Blakiston's  Son  &  Co. 


THE     'ia.A.VL.'Bi    rilESS     YORK    I"  A 


TO 

DR.  ROBERT  G.  LE  CONTE 

AS  A  TRIBUTE  TO 
HIS  ABILITY  AS  A  SURGEON 


PREFACE  TO  THE  FIFTH  EDITION 

The  manuscript  of  the  fifth  edition  of  this  manual  was  practically 
completed  by  Dr.  Stewart  at  the  time  of  his  death.  His  revision 
included  radical  changes  in  and  many  additions  to  those  portions 
deahng  with  surgical  technic,  surgical  infection  and  disinfection, 
wounds,  effects  of  heat  and  cold,  shock,  plastic  operations,  blood 
transfusion,  fractures,  and  amputations;  also  the  bones,  joints, 
nerves,  chest,  intestines,  rectum,  kidney  and  bladder.  He  wrote  a 
new  chapter  on  unnecessary  abdominal  section  and  rewrote  the 
sections  on  the  abdomen,  stomach,  operations  on  the  stomach, 
intestines,  intestinal  obstruction,  biliary  passages  and  the  pancreas. 

At  the  suggestion  of  Dr.  Stewart,  a  study  of  mihtary  surgery 
was  begun  in  191 5  with  service  in  the  French  army  and  continued 
until  my  discharge  from  the  American  army  in  19 19.  The  results 
of  this  mihtary  experience  have  been  incorporated  in  this  edition. 

Dr.  Edward  J.  Klopp,  Dr.  Henry  P.  Brown,  Dr.  W.  Edgar 
Christie  and  Dr.  S.  I.  Bloomhardt  have  given  valuable  assistance  in 
the  preparation  of  the  manuscript  and  the  reading  of  the  proof. 

The  pri\dlege  of  completing  the  manuscript  and  preparing  it  for 
publication  adds  to  the  many  obligations  incurred  during  the  years 
I  was  associated  with  Dr.  Stewart. 

Walter  Estell  Lee. 


EXTRACTS  FROM  THE 

PREFACE  TO  FIRST  EDITION 


The  following  pages  have  been  prepared  for  the  undergraduate, 
whose  crowded  hours  demand  a  manual  stripped  of  verbiage  and 
unessentials,  and  for  the  medical  practitioner  who  seeks  a  guide  to 
present-day  surgery.  The  chief  desire,  therefore,  has  been  to  set 
down  concisely  and  completely  those  facts  which  the  student  must 
know,  and  to  make  such  suggestions  in  diagnosis  and  treatment  as 
will  best  aid  the  physician  in  his  daily  practice.  For  these  reasons 
historical  matter  and  bibliographical  references  have  been  omitted, 
and  emphasis  has  been  laid  on  those  details  which  experience  teaches 
to  be  of  the  greatest  clinical  importance. 

F.  T.  S. 


CONTENTS 


Ch.\pter  Page 

I.  Diagnosis i 

II.  Anesthesia 21 

III.  Infection  and  Disinfection 42 

IV.  Surgical  Technic 59 

V.  Bandages 76 

V'l.  Inflammation  and  Repair 91 

VII.  Suppuration 106 

VIII.  Ulceration,  Sinus,  Fistula 116 

IX.  Gangrene 126 

X.  Contusions  and  Wounds  (Mechanical  Injuries) 138 

XI.  Chemical,  Thermal,  and  Electrical  Injuries i55 

XII.  General  Conditions  and  Special  Infections  Following  Wounds 163 

XIII.  Tumors  and  Cysts 214 

XIV.  Skin  and  Cutaneous  Appendages 245 

XV.  Vascular  System 265 

XVI.  Lymphatic  System 335 

XVII.  Nerves 342 

XVIII.  Muscles,  Tendons,  Bursae 362 

XIX.  Bones 374 

XX.  Joints 452 

XXI.  Head 500 

XXII.  Spine '  •    ■        •   539 

XXIII.  Ear,  Neck,  Thyroid  Gland 566 

XXIV.  Respiratory  System 586 

XXV.  Breast , 620 

XX VI.  Upper  Digestive  Apparatus 634 

XXVII.  Abdomen 665 

XXVIII.  Rectum  and  Anus 825 

XXIX.  Urinary  Organs 843 

XXX.  Genital  Organs  (Male  and  Female) 882 

XXXI.  Extremities 975 

IxDEX 1025 


MANUAL  OF  SURGERY 


CHAPTER  I 
DIAGNOSIS 

Diagnosis  is  the  process  whereby  the  nature  of  a  disease  is  deter- 
mined; the  term  is  appHed  also  to  the  result  of  this  process,  i.e., 
the  name  of  the  disease.  In  many  instances  the  condition,  as  a 
crushed  foot,  is  self-evident  and  a  direct  diagnosis  may  be  made;  in 
others  the  symptoms  suggest  two  or  more  afifections.  which  must 
be  distinguished  by  differential  diagnosis;  and  occasionally  a  diagno- 
sis by  exclusion  must  be  made;  thus  in  a  case  of  retroperitoneal  sar- 
coma, it  may  be  necessary  to  consider  all  the  other  forms  of  abdomi- 
nal tumor,  and  to  rule  them  out  one  by  one,  because  of  the  absence  of 
special  symptoms,  until  finally  the  real  cause  of  the  growth  is  deter- 
mined. In  order  to  be  complete  a  diagnosis  should  include  the  organ 
or  part  affected  {anatomical  diagnosis),  the  nature  of  the  aff'ection 
(pathological  diagnosis),  the  constitutional  change  resulting  from  or 
causing  the  local  lesion,  the  presence  or  absence  of  independent  or 
associated  maladies,  and  the  individuality  of  the  patient. 

A  diagnosis  is  made  by  interrogating  the  patient  (subjective 
symptoms)  and  by  physical  examination  (objective  symptoms  or  signs). 
The  chief  factors  in  diagnosis  are  to  obtain  correct  facts,  to  interpret 
them  properly,  to  know  what  to  look  for,  and  above  aU  to  look. 
"  More  mistakes  are  made  by  want  of  looking  than  by  want  of  know- 
ing." In  practice  the  analytical  method  is  usually  employed; 
the  attention  is  first  directed  to  the  offending  part,  and  by  examina- 
tion, coupled  with  questioning  the  patient,  one  considers  the  condi- 
tions most  likely  to  be  the  cause  of  the  symptoms,  and  then  by  further 
examination  the  diagnosis  is  finally  reached.  The  synthetical  or 
historical  method  is  more  scientific,  more  accurate,  and  better  adapted 
for  the  keeping  of  written  records.  It  consists  of  (a)  the  history 
(anamnesis),  which,  with  the  name  of  the  patient  and  the  date  of 
examination,  includes  (i)  the  age,  (2)  address  and  nationality,  (3) 
sex,  (4)  social  condition,  (5)  family  history,  (6)  previous  history, 
and  (7)  the  history  of  the  present  illness;  and  (b)  the  physical  exami- 


2  MANUAL  OF  SURGERY 

nation  (status  presens),  which  comprises  (8)  an  examination  of  the 
affected  part,  (9)  an  examination  of  regions  clinically  related  to  the 
affected  part,  and  (10)  a  general  examination  of  the  whole  body. 

1.  The  apparent  as  well  as  the  real  age  should  be  noted.  In 
childhood  irritability  of  the  nervous  system  is  marked,  and  high 
fever  and  convulsions  may  be  caused  by  trivial  affections  which  would 
cause  no  such  disturbances  in  the  adult.  A  mahgnant  neoplasm  in  a 
child  would  probably  be  a  sarcoma,  in  later  life  a  carcinoma.  Ulcers 
in  children  may  be  due  to  tuberculosis  or  congenital  syphilis;  in 
adults  syphilitic  and  traumatic  ulcers  are  frequent;  later  in  life  the 
varicose  ulcers  and  epitheliomata  predominate.  In  the  child  an 
injury  to  an  extremity  may  result  in  a  greenstick  fracture  or  epi- 
physeal separation,  the  same  in  an  adult  might  cause  a  complete 
fracture  or  a  dislocation.  In  intestinal  obstruction  one  would  sus- 
pect imperforate  anus  in  the  new  born,  intussusception  in  infancy, 
and  impacted  feces  or  cancer  in  old  age.  In  children  difficulty  in 
urination  would  probably  be  due  to  phimosis  or  calculus,  in  adults 
to  stricture,  in  old  age  to  enlarged  prostate.  In  childhood  infantile 
paralysis,  infantile  scur\y,  congenital  syphilis,  rickets,  adenoids, 
prolapse  of  the  anus,  rectal  polypi,  malformations,  nevi,  noma, 
foreign  bodies  in  the  air  passages,  tuberculous  lymph  glands,  acute 
infectious  osteomyelitis,  postpharyngeal  abscess,  hemophilia,  renal 
sarcoma,  hydrocephalus,  cretinism,  and  intussusception  are  common; 
in  adolescence  epiphyseal  separation,  gastric  ulcer,  osteoma,  chondroma, 
tuberculosis  of  bones  and  joints,  and  sexual  disorders  are  frequent; in 
middle  age  aneurysm,  carcinoma,  floating  kidney,  mollitiesossium,  and 
gallstones  are  most  apt  to  occur ;  in  old  age  hypertrophy  of  the  prostate 
and  degeneration  of  the  circulatory  apparatus,  leading  to  gangrene 
and  other  disorders,  are  prone  to  develop.  Hernia  is  most  frequent 
at  the  extremes  of  life.  Infancy  and  old  age  do  not  stand  operations 
well,  but  infants  who  escape  the  immediate  dangers  of  operation 
often  convalesce  more  rapidly  tha;n  adults. 

2.  Not  only  the  present,  but  previous  addresses  should  be  ascer- 
tained, as  well  as  the  place  of  birth.  Goiter  is  prevalent  in  moun- 
tainous regions;  leprosy  in  Norway  and  the  tropics;  bilharzia  hema- 
tobia,  tetanus,  filariasis,  and  hepatic  abscess  in  the  tropics;  rachitis 
in  densely  populated  centers;  vesical  calculus  in  India  and  parts  of 
England;  hydatid  disease  in  Iceland  and  Australia.  The  Xegrojs 
more  susceptible  to  tuberculosis,  aneurysm,  elephantiasis,  tetanus, 
and  benign  neoplasms,  especially  the  fibromata;  less  Hable  to  malig- 
nant disease,  stone  in  the  bladder,  varicose  veins,  appendicitis, 
congenital  deformity,  enlarged  prostate,  and  gall-stones;  and  less 


DIAGNOSIS  3 

resistant  to  operative  procedures.  The  Ilebreiv  suffers  frequently 
from  intestinal  and  rectal  disorders,  arteriosclerotic  gangrene,  and  is 
more  prone  to  develop  diabetes  with  its  surgical  complications;  his 
symptoms  should  be  analyzed  with  due  consideration  to  his  highly 
sensitive  nervous  system. 

3.  The  sex  is  occasionally  of  some  importance  in  making  a 
diagnosis.  Vomiting  or  an  abdominal  tumor  in  a  woman  should 
automatically  connote  pregnancy.  Excluding  diseases  of  the 
reproductive  organs,  females  are  more  liable  to  goiter,  floating  kid- 
ney, enteroptosis,  gall-stones,  mollities  ossium,  Raynaud's  disease, 
myxedema,  stricture  of  the  rectum,  tuberculous  peritonitis,  arthritis 
deformans,  hysteria,  and  other  functional  nervous  troubles,  but  they 
stand  operations  better  than  men.  Males  are  more  apt  to  develop 
aneurysm,  actinomycosis,  appendicitis,  cerebral  abscess,  cystic  kidney, 
cirrhosis  of  the  liver,  Dupuytren's  contraction,  hematoma  auris, 
hemophilia,  intussusception,  lymphadenoma,  pancreatitis,  stricture 
of  the  urethra,  stone  in  the  bladder,  diverticula  of  the  bladder, 
cancer  of  the  lip,  stomach  and  rectum,  and  conditions  produced  by 
exposure,  hard  work,  and  injurious  habits. 

4.  Under  the  social  condition  note  whether  the  patient  is  single  or 
married,  widow  or  widower.  If  a  woman,  elicit  the  menstrual  his- 
tory, the  amount  and  character  of  leukorrhea,  the  number  of  children 
and  miscarriages,  the  date  of  the  last  confinement,  and  the  presence 
or  absence  of  puerperal  complications.  Ascertain  the  nature  of 
previous  occupations  as  well  as  the  present  one.  Active  occupations 
predispose  to  hernia,  aneurysm,  and  various  forms  of  injury;  seden- 
tary occupations  to  gall-stones,  hemorrhoids,  ulcer  of  the  stomach, 
and  functional  neuroses;  standing  occupations  to  varicose  veins  and 
flat-foot.  Certain  occupations,  by  forcing  the  individual  to  assume  a 
particular  attitude  or  to  use  a  certain  set  of  muscles,  produce  altera- 
tions in  the  form  of  the  body,  thus  the  shoemaker,  tailor,  and  rag- 
picker become  round  shouldered,  and  one  who  carries  a  load  on  the 
same  shoulder  day  after  day,  or  who  uses  one  arm  or  leg  constantly,, 
may  develop  scoliosis.  Constant  pressure  on  a  part,  necessitated  by 
many  occupations,  may  produce  deformity,  callosities,  bursse,  and 
even  neoplasms.  Skin  handlers  and  wool-sorters  are  predisposed 
to  anthrax;  hostlers  to  glanders  and  tetanus;  butchers,  doctors,  and 
veterinarians  to  anatomical  tubercle  and  other  infections;  painters^ 
potters,  plumbers,  lead-makers,  tailors,  an,d  seamstresses  to  lead 
poisoning;  match-makers  to  phosphorous  necrosis  of  the  lower  jaw;, 
morocco  workers  and  those  who  use  acids  to  ulcers  of  the  hands  and 
forearms;  and  those  who  handle  grain  to  actinomycosis. 


4  MAXUAL  OF  SURGERY 

5.  The  family  history  includes  an  investigation  into  the  diseases 
which  have  occurred,  or  the  cause  of  death,  in  the  parents,  grand- 
parents, uncles  and  aunts,  brothers  and  sisters,  husband  or  wife,  and 
children.  Especially  to  be  inquired  for  are  calculus,  malformations, 
hemophilia,  syphilis,  tuberculosis,  rheumatism,  alcoholism,  malig- 
nant tumors,  and  nervous  affections. 

6.  In  the  previous  history  note  the  habits  of  the  individual,  espe- 
cially regarding  alcohol,  which  predisposes  to  aneurysm,  dehrium 
tremens,  tuberculosis,  neuritis,  etc.;  tobacco,  which  predisposes  to 
carcinoma  of  the  mouth  and  nervousness;  tea  and  coffee,  ^^^th  refer- 
ence to  neuroses  and  gastric  disorders;  and  the  sexual  life,  particu- 
larly as  to  excesses  and  masturbation.  Inquiry  should  be  made  also 
for  pre^^ous  injuries,  diseases,  and  operations.  Injuries  may  be 
followed  by  sarcoma,  tuberculosis,  epilepsy,  abscesses,  and  many 
other  disorders.  Among  the  diseases  which  may  have  occurred  the 
most  important  are  syphiHs  and  tuberculosis.  Certain  diseases  pre- 
dispose to  subsequent  attacks  of  the  same  malady;  among  such  are 
appendicitis,  salpingitis,  gall-stones,  kidney-stones,  erysipelas,  delir- 
ium tremens,  neuralgia,  rheumatism.  Others  render  a  patient  more 
vulnerable  to  dissimilar  affections;  appendicitis,  gall-stones,  and 
osteomyeHtis  often  follow  typhoid  fever;  stricture  of  any  of  the 
canals  of  the  body,  ulceration:  involving  those  canals;  vesical  calcu- 
lus, renal  colic;  arthritis,  gonorrhea.  Operations  are  responsible 
for  a  host  of  e\als,  e.g.,  laparotomy  may  be  followed  by  hernia, 
adhesions,  or  intestinal  obstruction;  ovariectomy  by  amenorrhea; 
gastroenterostomy  by  ulcer  of  the  jejunum;  thoracotomy  by  scolio- 
sis; trephining  by  epilepsy;  thyroidectomy  by  tetany,  myxedema,  or 
aphonia.  The  history  of  removal  of  a  tumor  may  explain  obscure 
symptoms  due  to  metastases.  We  recently  saw  a  case  in  which  a 
hernia  cerebri  was  incised  for  an  abscess,  a  mistake  that  could  not 
have  occurred  had  the  physician  known  that  a  decompressive  opera- 
tion had  been  performed. 

7.  The  history  of  the  present  iUness  includes  not  only  the  symp- 
toms, but  the  supposed  cause,  the  duration,  the  manner  of  onset,  and 
the  previous  treatment.  As  to  the  supposed  cause,  there  may  be  a 
history  of  exposure  to  one  of  the  infective  diseases,  such  as  erysipelas 
or  syphihs;  in  this  connection  it  is  important  to  ascertain  the  time 
elapsing  between  the  exposure  to  infection  and  the  beginning  of  the 
symptoms,  i.e.,  the  period  of  incubation.  The  duration  sometimes 
has  considerable  bearing  on  the  diagnosis,  e.g.,  a  tumor  which 
has  lasted  a  number  of  years  is  probably  benign,  one  which  has  lasted 
but  a  few  months  and  is  growing  rapidly  is  probably  mahgnant. 


DIAGNOSIS  5 

Time  is  a  sure  diagnostic  agent  in  pregnancy.  The  onset  is  sudden 
in  appendicitis,  perforative  peritonitis,  various  colics,  and  acute  in- 
fections; aneurysm,  tumors,  ascites,  and  strictures  of  various  kinds 
come  on  slowly.  The  previous  treatment  may  be  of  assistance  in 
diagnosis;  it  may  have  failed,  e.g.,  a  tumor  or  ulcer  unmoditied  by 
antiluetic  drugs  is  probably  not  syphilitic,  chills  uninfluenced  by 
quinin  are  not  malarial;  it  may  have  succeeded,  e.g.,  a  scrotal  tumor 
disappearing  temporarily  after  withdrawal  of  a  serous  fluid  is  a 
hydrocele,  after  taxis  a  hernia;  it  may  have  intensified  the  symptoms, 
e.g.,  intestinal  obstruction  is  made  worse  by  purgatives,  internal 
hemorrhage  by  stimulants;  or  it  may  have  created  additional  mis- 
chief, e.g.,  drug  eruptions,  mercurial  stomatitis,  catheter  cystitis, 
carboHc  acid  gangrene,  iodoform  dehrium,  splint  sores,  crutch  palsy, 
ligature  sinus,  paraffin  tumor,  X-ray  burn,  cystoscopic  ulcer.  It 
may  also  obscure  the  diagnosis,  e.g.,  chancre  and  epithelioma  may  be 
disfigured  by  caustics,  the  symptoms  of  peritonitis  may  be  clouded 
by  opium,  and  an  unconscious  man  who  has  been  given  whiskey  may 
be  wrongly  treated  as  an  alcoholic. 

8.  The  local  examination  needed  will  usually  be  indicated  by  the 
patient. 

By  inspection  the  size,  shape,  situation,  and  color  of  the  lesion 
may  be  determined,  as  well  as  abnormal  motion,  and  the  lesion  may 
be  studied  with  reference  to  the  influence  of  posture,  active  or 
passive  motions,  etc. 

Whenever  possible  the  size  of  a  lesion  should  be  expressed  in 
exact  terms,  thus  a  tumor  may  be  measured  with  calipers  or  tape 
measure,  instead  of  being  compared  in  size  with  an  orange  or  other 
object.  The  length  of  a  limb  compared  with  that  of  its  fellow  is 
of  the  greatest  value  in  the  diagnosis  of  fractures  and  dislocations, 
as  are  also  the  length  of  the  urethra  in  enlarged  prostate,  the  width 
of  the  intercostal  spaces  in  empyema,  and  the  size  of  the  head  in  hy- 
drocephalus and  microcephalus. 

The  shape  may  be  accurately  determined  by  a  plaster  cast, 
soft  lead  strips,  photographs,  or  autoprints,  e.g.,  in  flat-foot.  It 
is  frequently  of  assistance  in  recognizing  surgical  conditions,  es- 
pecially fractures  and  dislocations.  As  other  examples  may  be 
mentioned  the  notched  teeth  of  hereditary  syphiHs,  the  pear-shaped 
swelling  of  a  hydrocele,  and  the  fusiform  enlargement  of  a  tubercu- 
lous joint. 

The  situation  of  a  lesion  may  indicate  not  only  the  anatomical 
but  also  the  pathological  diagnosis  (see  "Diagnosis  of  Ulcers  and 
Tumors"). 


6  ilAJSrUAL  OF  SURGERY 

The  color  should  always  be  observed.  Localized  yellowish 
discoloration  may  be  caused  by  xanthoma,  an  old  bruise,  or  a  nitric 
acid  or  iodin  stain;  bronze  patches  by  syphilis,  tuberculosis,  scurvy, 
abdominal  tumors,  oil  of  cade,  blistering  agents,  exposure  to  electric 
light  or  the  X-ray,  and  the  pressure  of  garters,  belts,  or  collar 
buttons;  white  patches  by  ergotism,  scars,  frost  bite,  carbohc  acid, 
leukoplakia,  Raynaud's  disease,  neuritis,  and  leprosy;  redness 
by  acute  inflammation  or  hyperemia  (disappears  on  pressure  but 
returns  immediately  on  removal  of  the  pressure),  or  by  dyes,  etc. 
(does  not  disappear  on  pressure  and  may  be  washed  off);  blueness, 
or  hvidity.  by  venous  obstruction,  nevus  (returns  quickly  after 
pressure  is  removed),  beginning  gangrene  (returns  slowly  after 
the  relief  of  pressure),  and  ecchymosis  (unaffected  by  pressure); 
blackness  by  moles,  warts,  gangrene,  and  melanotic  sarcoma;  greenish 
discoloration  by  chloroma;  change  of  color  by  nevi;  and  linear  dis- 
coloratiofi  by  lymphangitis,  rarely  phlebitis  and  neuritis.  The 
mingling  of  purple  and  red  is  often  observed  over  malignant  growths. 
Petechia  and  ecchymosis  are  unaffected  by  pressure;  they  occur  in 
many  diseases,  but  it  will  suffice  here  to  mention  only  those  which 
interest  the  surgeon,  viz.  scurvy,  hemophilia,  iodism,  jaundice, 
pyemia,  septicemia,  snake  poisoning,  and  lightning  stroke.  Oc- 
curring several  days  after  an  injury,  ecchymosis  indicates  rupture 
of  some  deep  structure,  such  as  muscle  or  bone. 

Absence  of  motion  is  noticed  in  most  inflammatory  troubles, 
e.g.,  the  chest  in  pleurisy,  the  abdomen  in  peritonitis;  it  is  caused 
by  a  tonic  contraction  of  the  muscles,  which  gives  another  im- 
portant sign,  rigidity.  Pulsation  may  be  expansile  (the  swelhng 
enlarges  in  all  its  diameters  with  each  cardiac  systole),  e.g.,  in 
aneurysm,  tumors  communicating  with  the  cranial  cavity,  and 
very  vascular  growths,  such  as  goiter,  some  sarcomata,  and  certain 
angiomata;  or  transmitted  fthe  movement  is  in  one  direction  only), 
e.g.,  in  tumors  situated  over  an  artery  and  in  the  abdomen  of  nervous 
individuals.  Transmitted  pulsation  ceases  if  the  tumor  can  be  lifted 
or.  by  posture,  made  to  fall  away  from  the  artery.  Increased 
motion  is  exemplified  in  the  hurried  respiration  of  intrathoracic 
disease,  and  the  active  peristalsis  of  intestinal  obstruction. 

In  addition  to  the  aids  to  the  eye  which  have  already  been 
mentioned  are  the  microscope,  instruments  for  looking  into  cavities 
of  the  body  (ophthalmoscope,  laryngoscope,  bronchoscope,  cystoscope, 
etc.).  aspiration  to  determine  the  contents  of  a  cavity  or  swelling, 
and  exploratory  incision.  Diaphany,  or  translucency,  is  employed 
to  detect  disease  of  the  maxillary  antrum,  by  placing  a  light  in  the 


DIAGNOSIS  7 

moiilh;  to  determine  the  size  of  the  stomach,  by  passing  a  light 
into  this  organ;  and  to  ascertain  the  nature  of  some  swellings,  such 
as  hydrocele  and  meningocele,  by  placing  the  tumor  between  the 
light  and  the  eye,  in  a  dark  room,  and  looking  through  the  barrel 
of  a  stethoscope  or  a  tube  of  paper.  'J'he  X-ray  is  considered  on 
a  later  page. 

Palpation  is  used  to  corroborate  inspection,  to  ascertain  the 
size,  shape,  position,  etc.,  of  a  lesion  which  cannot  be  seen,  e.g., 
by  rectal  or  vaginal  examination;  and  to  determine  the  consistency, 
sensation,  mobility,  and  local  temperature.  The  consistency  of 
normal  tissues  may  be  modified  by  the  presence  of  solids,  fluids,  or 
gases.  Solids,  of  which  the  most  prominent  example  is  tumor 
formation,  may  cause  the  tissues  to  become  harder  (osteoma, 
etc.)  or  softer  (myxoma,  etc.).  Fluid  infiltrates  the  tissues  giving 
rise  to  edema,  or  accumulates  in  a  cavity  giving  rise  to  fluctuation. 
Edema,  which  is  shown  by  the  persistence  of  an  indentation  after 
digital  pressure,  occurs  in  contusions,  inflammations,  suppuration, 
obstruction  to  the  venous  or  lymphatic  circulation,  extravasation 
of  urine,  and  in  diseases  of  the  heart,  lungs,  liver,  and  blood.  Hyster- 
ical edema  and  myxedema  do  not  pit  on  pressure.  Fluctuation  is 
the  wave  felt  by  the  hand  on  one  side  of  a  swelling  when  a  sharp 
tap  is  given  to  the  other  side.  In  order  to  obviate  the  mistake 
due  to  a  wave  transmitted  through  the  skin  and  subcutaneous 
tissues,  the  hand  of  an  assistant  may  be  placed  on  the  swelling, 
between  the  hands  of  the  examiner.  This  sign  is  often  difficult  to 
obtain  when  the  fluid  lies  beneath  firm  fascia  or  thick  muscle,  is 
small  in  quantity,  or  under  great  tension,  and  it  is  often  fallacious 
in  semisolid  tumors.  Another  sign,  which  is  often  called  fluctuation, 
is  the  raising  of  the  fingers  of  one  hand  when  the  fingers  of  the  other 
hand  push  into  the  swelling;  it  may  be  obtained  in  normal  tissues, 
in  soft,  elastic  or  movable  tumors,  and  in  tumors  containing  gas, 
as  well  as  in  swellings  which  contain  fluid.  Error  may  sometimes 
be  avoided  in  eliciting  this  sign,  e.g.,  in  muscular  tissue,  by  testing 
it  longitudinally  as  well  as  transversely.  Gas  in  the  tissues  (em- 
physema) causes  a  doughy  swelling  which  crepitates  on  pressure. 
This  crepitus,  which  is  crackling  in  character,  should  not  be  confused 
with  that  of  fracture  or  osteoarthritis,  which  is  harsh  and  osseous; 
of  epiphyseal  separation,  which  is  soft  and  cartilaginous;  of  synovial 
inflammation,  which  is  creaking  and  leathery;  or  with  that  of  blood 
clot  or  hydatid  disease,  which  is  moist  and  yielding.  In  certain 
bone  diseases  fcysts,  sarcomata,  craniotabes,  disease  of  the  frontal 
and  maxillary  sinuses)  a  crackling  sensation  may  be  obtained  on 


8  MANUAL  OF  SURGERY 

pressure  (parchment  crepitus),  owing  to  thinning  of  the  osseous 
tissue;  and  in  synovial  inflammations  containing  rice  bodies  a  special 
form  of  crepitation  may  be  obtained  by  forcing  the  bodies  along 
the  sac.  Related  to  crepitus  is  tJirill.  which  may  be  felt  over  an 
aneurysm  or  vascular  tumor,  and  sometimes  in  the  case  of  a  foreign 
body  in  the  air  passages. 

Aside  from  pain,  disorders  of  sensation  (hyperesthesia,  hypesthe- 
sia,  anesthesia,  paresthesia,  alteration  of  the  heat  sense  or 
thermesthesia,  of  the  pressure  sense,  etc.)  are  mainly  of  value 
in  diseases  and  injuries  of  the  nervous  system.  Pain  is  the  most 
frequent  symptom;  and  tenderness,  which  is  of  more  value  to  the 
surgeon  than  pain,  is  pain  on  pressure.  Its  situation  does  not 
always  indicate  the  seat  of  disease.  In  a  lesion  near  the  origin  of 
a  nerve,  pain  may  be  felt  in  the  periphery;  in  a  lesion  at  the  periphery, 
at  the  end  of  another  branch  of  the  same  nerve.  Certain  diseases 
of  the  brain  and  spinal  cord  produce  pain  at  the  nervx  terminations. 
General  pain  or  aching  of  the  body  may  be  present  in  acute  infections 
or  intoxications.  If  pain  corresponds  exactly  to  the  distribution 
of  a  nerve,  the  cause  will  probably  be  found  along  the  trunk  or 
at  the  root  of  that  nerve;  the  pain  of  a  local  lesion  does  not  confine 
itself  to  the  distribution  of  a  single  nerve.  Absence  of  tenderness 
in  a  painful  region  genera  ly.  but  not  invariably,  indicates  that  the 
pain  is  referred,  but  even  in  referred  pain  tenderness  may  be  present. 
Pain  in  the  top  or  the  back  of  the  head  may  be  due  to  pelvic  disease; 
in  the  supraorbital  regions  and  the  temples  to  disease  of  the  eye; 
in  the  side  of  the  head  and  the  ear  to  disease  of  the  teeth;  in  the 
forehead  to  disease  of  the  nose  or  the  nasopharynx;  above  the 
left  clavicle  to  disease  of  the  colon  or  the  diaphragm;  in  the  side 
of  the  chest  to  disease  of  the  vertebra  or  the  spinal  cord;  in  the 
right  shoulder  to  hepatic  disease;  in  the  nipple  and  the  breast  to 
uterine  disease;  between  the  shoulders  to  disease  of  the  stomach 
and  intestines;  in  the  sacral  region  to  intrapelvic  disorders  or  disease 
of  the  testicle,  rectum,  or  hip;  in  the  epigastrium  or  any  portion 
of  the  abdomen  to  diseases  of  the  spine  or  the  spinal  cord;  along 
the  outer  side  of  the  thigh  and  in  the  heel  to  ovarian  disease;  at  the 
inner  side  of  the  knee-joint  to  disease  of  the  hip;  in  the  sole  of  the 
foot  to  disease  of  the  prostate,  ovary,  or  rectum;  in  the  head  of  the 
penis  to  vesical  calculus. 

The  character  of  pain  is  sharp,  knife-like,  or  lancinating  in 
acute  inflammations  of  serous  membranes;  dull  or  bruise-like  in 
inflammations  of  mucous  membrane,  connective  tissue,  and  paren- 
chymatous \'iscera,   and  in  chronic  inflammation;  paroxysmal  in 


DIAGNOSIS  9 

floating  kidney,  labor,  neuralgia,  colics,  spinal  tumor,  and  intestinal 
obstruction;  shifting  in  hysteria,  rheumatism,  and  flatulence; 
gnawing  or  boring  in  cancer,  diseases  of  bone,  and  sometimes  in 
lithemia;  aching  in  muscles;  burning  and  itching  in  the  skin ;  smarting 
or  scalding  in  the  urethra;  nauseating  in  the  testicle;  throbbing  in  sup- 
purative inflammations;  bearing  down  {tenesmus)  in  cystitis,  enlarged 
prostate,  proctitis,  and  labor.  Pain  which  suddenly  ceases  may  be 
due  to  the  passage  of  a  stone,  the  sudden  overcoming  of  some 
obstruction,  or  to  beginning  gangrene.  It  is  also  studied  with  refer- 
ence to  the  efl"ect  of  pressure,  change  of  weather,  movements,  etc. 
Most  pains  are  worse  at  night,  particularly  those  due  to  carcinoma, 
diseases  of  bone,  rheumatism,  locomotor  ataxia,  and  neuritis. 
Much  allowance  must  be  made  for  the  variation  in  individual 
tolerance  to  pain.  The  degree  of  tenderness  may  to  some  extent 
be  gauged  by  the  effect  upon  the  facial  expression  and  the  pulse, 
and  by  the  presence  or  absence  of  involuntary  muscular  rigidity. 

Abnormal  mobility  is  found  in  fractures,  ruptures  of  ligaments, 
dissolution  of  joints,  floating  kidney,  and  kindred  affections;  more 
or  less  immobility  in  ankylosis,  inflammatory  or  neoplastic  infiltra- 
tions, and  in  growths  springing  from  a  fixed  portion  of  the  body, 
e.g.,  osteoma.  Under  this  heading  may  be  mentioned  also  the 
value  of  palpation  in  ascertaining  the  presence  or  absence  of  motion 
due  to  muscular  contractions,  e.g.,  in  the  bowel  (peristalsis),  uterus, 
fetus,  and  muscles  under  investigation  for  paralysis. 

The  local  temperature  is  elevated  in  inflammatory  diseases  and 
very  vascular  tumors,  lowered  in  gangrene  and  trophic  lesions. 
It  may  be  accurately  measured  with  a  surface  thermometer. 

As  aids  to  palpation  may  be  mentioned  probes  and  sounds, 
placing  the  patient  in  various  postures,  and  measures  for  relaxing 
muscles,  particularly  general  anesthesia. 

Percussion  is  employed  to  outline  organs,  determine  the  com- 
position of  accumulations  in  cavities  and  the  presence  of  gas  in 
tumors,  detect  points  of  tenderness,  and  occasionally,  as  in  hydro- 
cephalus and  certain  fractures,  to  elicit  the  cracked-pot  sound. 
Auscultation  is  used  to  detect  disease  in  the  chest,  the  presence 
or  absence  of  intestinal  peristalsis,  the  bruit  of  an  aneurysm,  the 
sound  of  a  fetal  heart,  the  succussion  splash  of  a  dilated  stomach, 
the  deglutition  sound,  and  the  garrulity  of  wounds  communicating 
with  the  respiratory  apparatus.  Crepitus  which  cannot  be  felt 
may  occasionally  be  heard,  e.g.,  in  fractures  of  the  ribs.  As  aids 
to  auscultation  may  be  mentioned  the  stethoscope,  the  phonen- 
doscope,  and  the  telephonic  probe. 


lO  MANUAL  OF  SURGERY 

The  sense  of  smell  may  reveal  necrosis  of  bone,  gangrene  of 
soft  tissues,  fecal  fistulae,  stercoraceous  vomitus,  and  ammoniacal 
urine.  The  odor  of  the  breath  is  of  value  in  diagnosticating  uremia, 
acetonemia,  diabetes,  diphtheria,  and  some  forms  of  poisoning.  The 
odor  in  pyemia  is  that  of  hay,  in  hepatic  abscess  liverish,  in  actino- 
mycosis earthy,  in  jaundice  and  peritonitis  musty,  in  the  critically 
ill  cadaveric. 

9.  An  examination  of  the  regions  clinically  related  to  the  affected 
part  is  of  the  greatest  importance.  A  part  should  always  be  com- 
pared with  that  of  the  opposite  side  of  the  body,  to  detect  deviations 
from  the  normal,  e.g.,  in  fractures  and  dislocations;  and  to  ascertain 
whether  the  same  lesion  is  present  on  both  sides,  e.g.,  hernia,  tuber- 
culous epididymitis,  chronic  mastitis,  salpingitis,  syphilitic  eruptions, 
and  many  other  conditions  are  often  bilateral.  In  local  infections 
and  neoplasms  the  anatomically  related  lymph  glands  must  be 
examined,  and  conversely  in  lymphadenitis  the  regions  which  the 
lymph  glands  drain  must  be  scrutinized.  One  should  make  sure 
the  pulse  is  present  below  fractures  and  dislocations,  motion  and 
sensation  below  wounds;  examine  the  superficial  veins  for  distention 
in  tumors,  the  muscles  for  atrophy  in  joint  disease,  the  spine  for 
scoliosis  in  asymmetry  of  the  lower  limbs,  the  knee  for  effusion  in 
fractures  of  the  femur,  the  liver  for  cirrhosis  in  hemorrhoids.  Blad- 
der symptoms  may  be  of  rectal  origin;  rectal  symptoms  due  to 
affections  of  the  genitourinary  organs. 

10.  A  careful  general  examination  is  too  often  neglected. 
Attention  need  be  called  only  to  the  fact  that  stomatitis  may  be 
caused  by  chronic  nephritis;  furunculosis  and  gangrene  by  diabetes; 
varicose  veins  of  the  leg  by  disease  of  the  heart;  amenorrhea  by 
anemia;  ulcer  on  the  sole  of  the  foot  by  disease  of  the  spinal  cord; 
and  to  the  fact  that  abdominal  disorders  may  be  simulated  by 
disease  of  the  lungs,  spine,  spinal  cord,  and  by  hysteria.  The  height 
and  weight  should  be  noted.  A  progressive  decrease  in  height  is 
found  in  diseases  like  arthritis  deformans.  The  patient's  best 
weight  and  his  present  weight  should  be  taken.  Cachexia  means 
marked  emaciation,  great  weakness,  and  profound  anemia;  it  is 
seen  in  carcinoma,  diabetes,  tuberculosis,  chronic  suppuration, 
large  ovarian  cysts,  congenital  syphilis,  organic  disease  of  the 
stomach,  stricture  of  the  esophagus,  and  in  obstructions  of  the 
thoracic  duct. 

The  facial  expression  is  of  great  value  to  the  experienced  eye. 
As  examples  may  be  mentioned  the  vacant  expression  of  adenoids, 
the  anxious  expression  of  peritonitis,   the  pale  frightened  face  of 


DIAGNOSIS  1 1 

acute  hemorrhage,  the  threatening  and  suspicious  facies  of  delirium 
tremens,  the  staring  expression  of  exophthahnic  goiter,  the  mask- 
like expression  of  paralysis,  the  unmeaning  grimaces  of  hysteria, 
the  risus  sardoniciis  of  tetanus,  and  the  weazened  face  of  hereditary 
syphilis.  The  Hip])ocratic  face — "The  sharp  nose,  hollow  eyes, 
colla])se(l  tem])les;  the  ears  cold,  contracted,  and  their  lobes  turned 
out;  the  skin  about  the  forehead  being  rough,  distended  and  parched; 
the  color  of  the  whole  face  brown,  black,  livid  or  lead  colored," — is 
the  face  of  impending  death. 

Posture: — ^Lying  on  the  back  and  constantly  slipping  toward 
the  foot  of  the  bed  is  seen  in  acute  infections  or  great  weakness; 
the  dorsal  position  with  both  legs  drawn  up  in  peritonitis;  the 
ventral  posture  in  intestinal  colic,  sometimes  in  abdominal  aneu- 
rysm and  spinal  caries.  The  patient  may  lie  upon  the  affected 
side  in  empyema,  and  be  coiled  up  on  one  side  in  cerebral  irritability 
and  in  various  forms  of  colic.  Great  restlessness  in  bed  indicates 
nervous  irritability,  acute  hemorrhage,  sometimes  shock;  it  is  a 
bad  sign  in  the  critically  ill.  The  body  may  be  bent  forward  so 
that  it  rests  upon  the  forehead  and  feet  (emprosthotonos) ,  backward 
so  that  it  rests  upon  the  occiput  and  heels  (opisthotonos),  or  laterally 
(pleurostJwtonos),  in  meningitis,  strychnin  poisoning,  tetanus,  or 
hysteria.  Orthopnea,  in  which  the  patient  sits  up  and  grasps  some 
firm  object  in  order  to  fix  the  accessory  muscles  of  respiration,  is 
often  observed  in  diseases  of  the  heart  and  lungs,  large  accumulations 
in  the  thorax  or  abdomen,  and  in  foreign  bodies  in  or  stenosis  of 
the  air  passages.  A  shuffling  gait  with  a  rigid  body  suggests  caries 
of  the  spine,  a  waddling  gait  coxa  vara  or  congenital  dislocation  of 
the  hips.  The  head  is  thrown  back  and  the  feet  apart  in  large 
abdominal  tumors  and  accumulations. 

The  pulse,  temperature,  and  respirations  should  be  taken,  and 
one  should  ascertain  the  condition  of  the  organs  of  digestion,  the 
spleen,  the  genitourinary  apparatus,  the  heart  and  blood  vessels, 
the  lungs,  the  organs  of  special  sense,  and  the  nervous  system, 
especially  with  reference  to  hysteria  and  locomotor  ataxia,  both 
of  which  may  mimic  various  surgical  affections.  However,  the 
presence  of  either  of  these  nervous  maladies  may  coexist  in  one 
who  needs  surgical  treatment,  and  sometimes  a  surgical  lesion 
causes  hysteria  or  is  the  result  of  tabes.  In  special  cases  chemical, 
microscopical,  and  bacteriological  examinations  of  various  secretions, 
excretions,  and  discharges  may  be  required. 

Blood  Examinations. — The  red  cells  may  be  increased  in  number 
(polycythemia)   when  the  blood  is  concentrated,  e.g.,  as  the  result 


12  MANUAL  OF  SURGERY 

of  profuse  sweating,  vomiting,  diarrhea,  starvation,  and  exercise; 
when  oxygenation  is  impaired,  e.g.,  by  high  altitudes,  cyanosis, 
and  cardiac  and  puhnonary  disease;  in  erythremia,  hepatic  insufh- 
ciency,  myxedema,  purpura,  diabetes,  and  direct  blood  transfusion; 
and  as  the  result  of  active  hemogenesis,  thus  after  hemorrhages 
the  blood-making  organs  may  in  time  supply  more  than  enough 
cells  to  replace  those  which  have  been  lost.  Oligocythemia  (decrease 
in  the  number  of  red  cells)  takes  place  when  the  blood  is  diluted 
by  the  ingestion  of  large  amounts  of  fluid,  saline  infusion,  and  when 
the  genetic  powers  are  overtaxed,  e.g.,  by  child-birth,  lactation,  and 
at  puberty.  Anemia,  or  a  reduction  in  the  number  of  red  cells 
and  the  percentage  of  hemoglobin,  may  be  primary,  in  which  no 
cause  can  be  found,  e.g.,  pernicious  anemia  and  chlorosis;  or  second- 
ary, the  most  common  causes  of  which  are  acute  and  chronic  hem- 
orrhage, bacterial  infections,  malignant  growths,  malnutrition, 
intestinal  and  blood  parasites,  and  chemical  poisons,  such  as  lead, 
mercury,  and  the  coal-tar  derivatives. 

Mikulicz  believed  that  no  general  anesthetic  should  be  given 
when  the  hemoglobin  is  below  30  per  cent.,  but  surgeons  do  not 
adhere  to  this  rule,  excepting,  perhaps,  in  cases  in  which  delay  will 
result  in  some  improvement  in  the  quality  of  the  blood. 

Leukocytosis,  particularly  of  the  polynuclear  cells,  indicates  an 
inflammatory  lesion,  but  only  when  other  symptoms  of  the  lesion  are 
present,  and  only  when  other  causes  for  an  increase  in  the  white 
cells  have  been  excluded;  hence,  from  the  standpoint  of  surgical 
diagnosis,  leukocytosis  may  be  divided  into  the  noninfectious  and  the 
infectious. 

Noninfectious  leukocytosis  may  be  physiological,  e.g.,  in  infants, 
during  pregnancy  and  digestion,  and  after  exercise  and  bathing.  It 
may  occur  in  shock,  cyanosis,  rickets,  cirrhosis  of  the  liver,  chronic 
nephritis,  gout,  carcinoma,  and  sarcoma  (the  lymphocytes  being  in 
excess  in  lymphosarcoma).  It  may  follow  the  injection  of  toxins, 
including  vaccins;  the  administration  of  certain  drugs,  e.g.,  the 
salicylates,  coal-tar  derivatives,  potassium  chlorate,  camphor, 
digitalis,  some  of  the  aromatic  oils,  thyroid  extract,  and  quinin; 
acute  and  chronic  hemorrhage,  general  anesthesia,  and  consequently 
the  various  surgical  operations  (a  rising  leukocytosis  after  the  second 
or  third  day,  however,  would  be  highly  presumptive  of  a  septic 
complication).  The  leukocytosis  of  lymphatic  and  of  splenomedul- 
lary  leukemia  are  easily  recognized  by  the  increase  in  the  lymphocytes 
in  the  former,  and  of  the  mvelocvtes  in  the  latter.     Agonal  leukocvto- 


DIAGNOSIS  13 

sis,  which  occurs  just  before  death,  is  due  to  the  gathering  of  the 
leukocytes  along  the  walls  of  the  capillaries  as  the  result  of  the  feeble 
circulation,  or  to  a  terminal  infection. 

Infectious  leukocytosis  may  accompany  any  of  the  bacterial 
diseases,  except  uncomplicated  influenza,  measles,  rubeola,  typhoid, 
paratyphoid,  malta  fever,  leprosy,  and  tuberculosis;  malaria  and 
trypanosomiasis,  which  are  due  to  protozoa,  also  fail  to  show  an 
increase  in  the  white  cells,  but  there  is  a  moderate  leukocytosis 
during  the  secondary  and  tertiary  stages  of  syphilis.  The  most 
important  infections  from  the  standpoint  of  surgical  diagnosis  are 
those  of  pyogenic  origin.  The  degree  of  inflammatory  leukocytosis 
depends  upon  the  virulence  of  the  microorganism  and  the  resisting 
powers  of  the  patient,  and  some  idea  of  the  nature  of  these  factors 
may  be  obtained  by  comparing  the  leukocyte  count  with  the  general 
condition  of  the  patient.  If  leukocytosis  is  slight  (12,000  to  15,000) 
or  absent,  it  means,  when  the  general  condition  is  good,  that  the 
infection  is  trivial,  well  encapsulated  or  chronic,  or,  when  the 
general  condition  is  bad,  that  the  infection  is  overwhelming.  If 
leukocytosis  is  marked  (20,000  or  higher)  it  means,  when  the  general 
condition  is  good,  that  the  infection,  although  serious,  is  probably 
being  localized  or  conquered,  or,  when  the  general  condition  is  bad, 
that  the  infection,  although  actively  combated,  is  too  great  for  the 
patient's  resistance.  As  with  the  temperature,  pulse,  and  respira- 
tions, repeated  observations  are  of  more  value  than  a  single  observa- 
tion. A  rising  leukocytosis  indicates  a  spreading  infection  or  pus 
formation.  According  to  Hewitt  the  total  leukocyte  count  is  an 
index  of  the  patient's  resistance  to  the  infecting  organism,  and  the 
relative  polynuclear  count  an  index  of  the  severity  of  the  infec- 
tion. If  the  relative  polynuclear  count  is  between  75  and  80  per 
cent,  infection  is  probably,  if  between  80  and  85  usually,  and  if  above 
85  almost  certainly  present.  The  normal  polynuclear  count  is  from 
60  to  70  per  cent,  of  the  total  number  of  leukocytes. 

lodophilia  (iodin  reaction  in  the  leukocytes)  is  found  in 
septic  processes,  but  as  it  occurs  in  many  other  conditions,  e.g., 
malaria,  late  typhoid,  etc.,  it  is  of  little  value  to  the  clinician.  Eosino- 
philia  occurs  in  parasitic  diseases,  such  as  hydatid  cysts,  trichiniasis, 
anclylostomiasis,  and  filariasis,  but  also  in  asthma  and  certain  skin 
diseases,  hence  its  value  is  not  absolute.  The  presence  of  filaria  is 
readily  determined,  however,  by  a  microscopic  examination  of  the 
blood  during  the  night. 

An  estimation  of  the  coagulation  time  of  the  Mood  is  particularly 
indicated  in  cases  like  chronic  jaundice  and  hemophilia,  in  which 


14  MANUAL  OF  SURGERY 

operation  may  be  fatal  from  uncontrollable  oozing  of  blood.  Nor- 
mally it  is  from  three  to  six  minutes. 

Tests  for  hemolysis  and  agglutination  should  be  made  before 
direct  blood  transfusion,  and  in  hemolytic  jaundice.  The  aggluti- 
nation reaction  of  Widal  is  of  great  importance  in  the  diagnosis  of 
typhoid  fever.  Serodiagnosis  (complement  fixation  test)  is  routine 
in  syphilis,  and  only  occasionally  employed  in  gonorrhea,  pregnancy, 
carcinoma,  hydatid  disease,  and  several  medical  affections.  Chem- 
ical examination  of  the  blood  for  nonprotein  nitrogen  and  sometimes 
for  other  substances  is  used  in  estimating  the  functional  capacity 
of  the  kidney  (q.v.).  Examination  of  the  blood  for  bacteria  and 
acetone  is  sometimes  desirable,  both  for  diagnosis  and  prognosis. 

Among  the  diseases  which  may  simulate  surgical  conditions,  and 
which  may  be  excluded  by  a  blood  examination,  are  malaria  (malaria 
parasites),  typhoid  fever  (Widal  reaction  and  leukopenia),  lymphatic 
and  splenomedullary  leukemia  (enormous  leukocytosis,  particularly 
of  the  lymphocytes  in  the  former,  and  of  the  myelocytes  in  the  latter), 
and  lead  poisoning  (basophilic  granulations  in  the  red  cells).  It  may 
be  recalled  that  pneumonia,  which  may  simulate  intraabdominal 
inflammation,  causes  a  leukocytosis  and  that  Hodgkin's  disease 
produces  no  distinctive  blood  changes. 

THE  X-RAY 

The  X-ray  penetrates  substances  opaque  to  the  ordinary  forms 
of  light,  casts  shadows,  causes  fluorescence  of  certain  salts,  and 
has  the  same  chemical  action  upon  photographic  films  as  sunlight. 

The  apparatus  necessary  for  the  production  of  the  X-ray  con- 
sists of  a  sealed  glass  vacuum  tube  (Crookes  tube),  containing 
two  or  three  electrodes,  and  a  machine  capable  of  generating  elec- 
trical currents  of  high  voltage.  One  of  the  electrodes,  the  cathode, 
is  a  concave  metallic  disk,  which  is  connected  with  the  negative 
terminal  of  the  exciting  apparatus.  At  the  focus  of  this  reflector  is 
a  metalhc  disk  called  the  target.  The  electrode  connected  with  the 
positive  terminal  is  called  the  anode.  Electrical  discharges  suit- 
able for  exciting  a  Crookes  tube  may  be  obtained  from  static  ma- 
chines, high  frequency  coils,  the  ordinary  induction  coil,  or  prefer- 
ably from  the  more  modern  high-tension  transformer.  In  a  prop- 
erly excited  Crookes  tube  there  is  a  current  of  electricity  flowing 
toward  the  cathode,  from  the  concave  surface  of  which  it  is  focused 
upon  the  target.  As  far  as  we  know  the  rays  originate  at  this  point. 
The  green  fight  seen  in  an  excited  tube  is  due  to  fluorescence  of  the 


DIAGNOSIS  15 

glass  produced  by  the  rays,  which  themselves  are  invisible.  Coolidge 
has  invented  a  new  type  of  tube,  .which  is  particularly  valuable  for 
therapeutic  purposes.  Its  anode  is  a  solid  block  of  wrought  tungsten, 
its  cathode  a  spiral  of  tungsten  wire,  which  is  heated  to  a  delinite 
temperature  by  the  current  from  a  12-volt  storage  battery.  The 
high-tension  current  will  pass  through  the  tube  only  when  this 
spiral  is  heated  to  a  certain  degree  of  incandescence,  and  this  degree  of 
heat  determines  the  amount  of  current  that  can  be  passed  through 
the  tube.  Further,  the  voltage  of  the  high-tension  current  determines 
the  hardness  or  softness  of  the  X-rays  emitted,  so  that  by  means  of 
proper  meters  accurate  doses  of  the  X-rays  may  be  given.  The 
vacuum  in  the  Coolidge  tube  is  about  i.oco  limes  as  great  as  in  the 
ordinary  tube  and  needs  no  regulation. 

The  Fluoroscope  consists  of  a  piece  of  cardboard  on  one  side  of 
which  is  spread  a  thin  layer  of  finely  ground  crystals  of  barium 
platinocyanid,  potassium  platinocyanid,  or  tungstate  of  calcium. 
This  screen  is  mounted  in  an  apparatus  so  constructed  as  not  to 
expose  the  operator  to  the  X-rays  while  studying  the  patient. 
When  brought  near  an  active  Crookes  tube,  the  crystals  become 
luminous  and  give  off  a  faint  green  light.  The  transparency  of 
substances  to  the  X-rays  varies  according  to  their  atomic  weights.  If 
the  hand  be  placed  between  an  excited  tube  and  the  fluorescent 
screen,  the  softer  tissues  will  appear  as  faint  shadows,  and  the  bones, 
which  are  more  dense,  as  dark  shadows.  When  these  shadiows  fall 
upon  a  photographic  plate,  the  silver  bromid  is  changed  as  with 
light  rays,  and  if  the  plate  is  then  developed,  a  permanent  record  of 
the  shadows  is  obtained  (Radiogram,  or  Skiagram).  To  make  good 
pictures  requires  skill  and  much  time,  consequently  most  practitioners 
refer  their  cases  to  a  Rontgenologist.  The  physician,  however, 
should  have  some  knowledge  of  the  interpretation  of  plates,  be  famil- 
iar with  the  indications  for  the  use  of  the  X-ray  (diagnostic  and 
therapeutic),  and  know  the  dangers  which  may  arise. 

The  interpretation  of  X-ray  pictures  is  a  study  in  shadows,  which, 
like  those  cast  by  a  candle  light,  are  subject  to  distortion  in  size 
and  in  shape.  The  least  distortion  occurrs  when  the  object  is  very 
thin,  is  in  close  contact  with  the  screen  or  plate,  is  as  far  from  the 
tube  as  the  rays  are  effective,  and  when  the  object  and  the  target  are 
in  a  plane  perpendicular  to  the  plate,  hence  one  should  know  the 
distance  between  the  tube,  the  object,  and  the  plate,  the  angle  at 
which  the  picture  was  made,  and,  if  possible,  the  size  of  the  object 
(Figs.  I  and  2).  The  kind  of  tube  employed  also  influences  the 
results.     A  high  vacuum,  or  hard,  tube  gives  a  small  quantity  of 


i6 


MAXUAL  OF  SURGERY 


deeply  penetrating  rays  and  little  contrast  between  the  tissues 
of  different  densities;  a  low  vacuu^m.  or  soft,  tube  a  large  quantity  of 
feeble  rays  and  decided  contrast  between  the  various  tissues.  One 
must  be  familiar  with  the  shadows  of  normal  tissues  at  different  ages. 
In  the  child  the  bones  cast  faint  shadows  and  some  of  the  epiphyses 
are  not  visible  until  puberty.  Ununited  epiphyses  may  be  mistaken 
for  fragments  of  bone,  epiphyseal  junctures  for  lines  of  fracture. 
Other  sources  of  error  are  detective  plates;  finger  marks;  congenital 
abnormalities,  e.g..  a  bipartite  scaphoid  and 
extra  bones  (trigonum,  tibiale  externum, 
vesalianum.  ribs);  sesamoids;  grooves  for 
blood  vessels  and  suture  lines,  e.g.,  in  the 
skull;  dense  areas  in  the  skin  (warts,  scars, 
fibromata);  external  apphcations  (zinc, 
mercury,  iodin.  lead  water) ;  superimposed 
shadows,  which  may  be  recognized  by  taking 
a  second  plate  at  a  dift"erent  angle;  enlarged 
bronchial  glands,  simulating  aneurysm;  gas 
in  the  intestine;  fecal  masses,  calcified  lymph 
glands.  phleboKths,  and  like  conditions, 
which  may  be  mistaken  for  calculi  and 
foreign  bodies;  and,  owing  to  the  desire  to 
make  small  plates,  failure  to  include  the 
lesion  in  the  area  of  investigation. 

As  a  diagnostic  agent  the  fluoroscope 
permits  quick  and  easy  examinations,  but 
the  images  lack  detail,  so  that  small  foreign 
bodies,  and  fractures  without  deformity  are 
frequently    overlooked.     Consequently    the 


J^ 


Fig.  I. — Note  the  size  of 
the  object  (a)  and  its  shadow 
(b)  when  the  former  is  near      _  .  i  i       i  •    n  i 

the  tube  and  some  distance    fluoroscope  IS  employed   chiefly  to  observe 
from  the  plate;  and  of  the    ^j^g  movements  of  aneurvsms,  the  heart,  the 

object  (c)  and  its  shadow  (d)  _  '  '  .  . 

when  the  object  is  far  from    lungs,  the  diaphragm,  and   the  peristalsis  of 

the  tube  and  near  the  plate,     -v        .  i  j  •    a      i*  -t^u  j*  t. 

the  stomach  and  intestines,  ihe  radiograph 
gives  a  permanent  picture  with  delicate  detail  and  sharp  outlines  not 
found  in  the  fluoroscopic  image. 

These  pictures  are  of  great  value  in  localizing  foreign  bodies, 
either  extraneous,  such  as  bullets,  needles,  etc.,  or  those  formed 
wdthin  the  tissues,  such  as  renal  and  vesical  calculi.  Minute  frag- 
ments of  coal,  wood,  and  glass  other  than  lead-glass,  however, 
may  evade  detection,  particularly  if  overshadowed  by  bone,  or 
some  distance  from  the  plate.  A  preliminary  fluoroscopic  observa- 
tion is  made,  and  a  mark  placed  on  the  skin  directly  over  the  foreign 


DIAGNOSIS  17 

body.  Stereoscopic  plates  are  then  taken  to  determine  the  relation 
of  the  foreign  body  to  some  surgical  landmark.  To  obtain  stereo- 
scopic plates  it  is  necessary  to  have  a  plate  holder,  by  means  of 
which  plates  can  be  inserted  and  removed  without  disturbing  the 
part  to  be  skiagraphed.  Two  plates  are  exposed,  the  tube  being 
moved  horizontally  two  and  one-half  inches,  the  average  inter- 
pupillary  distance.  The  plates  are  now  developed  and  examined 
with  a  stereoscope,  when  the  depth  of  the  foreign  body  and  the 
perspective  of  the  various  planes  of  tissue  can  be  seen.  Even  the 
lines  in  the  skin  will  appear  if  a  thin  coating  of  bismuth  be  applied 
before  the  plates  are  made.  If  a  surgical  landmark  is  not  in  close 
proximity  to  the  foreign  body  a  special  localizing  technic  must  be 


\  "-iV. 


3i ii__aisS3>^ 


VV^: -^V-.^  .^.^V^ 


l;b^ 


Fig.  2. — Diagram  showing  distortions  produced  by  the  X-ray.  The  horizontal  line 
represents  the  X-ray  plate,  seen  in  profile;  the  objects  above,  broken  bones;  those  below 
the  shadows  as  seen  on  the  plate.  On  the  left  is  shown  an  oblique  fracture  with  overlap- 
ping, the  shadows  of  which  indicate  a  transverse  fracture  with  separation;  on  the  right  a 
transverse  fracture  with  no  overlapping,  the  shadows  of  which  indicate  an  oblique  frac- 
ture with  overlapping.  As  the  shadows  of  the  fragments  nearer  the  tube  are  larger  and 
less  distinct  than  those  close  to  the  plate,  an  expert  might  detect  these  errors  merely  from 
the  skiagraph,  but  a  novice  could  easily  be  deceived.  In  all  doubtful  cases  a  second 
plate,  at  right  angles  to  the  first,  should  be  taken  or  stereoscopic  plates  made. 

employed.  The  simplest  method  is  to  make  two  plates  in  planes  at 
right  angles  to  each  other.  Manges,  Sweet,  and  others  have  devised 
exceedingly  accurate  but  compHcated  forms  of  apparatus  for  deter- 
mining the  situation  of  a  foreign  body,  but  the  principle  of  all  is  that 
of  angulation,  as  in  the  method  here  described.  The  target  of  the 
X-ray  tube  is  fixed  directly  over  the  mark  on  the  skin,  the  distance 
between  the  target,  the  skin,  and  the  plate  being  measured. 
The  tube,  with  the  vertical  distance  from  the  plate  remaining 
constant,  is  moved  three  inches  to  the  left  and  an  exposure  made, 
then  three  inches  to  the  right  of  the  starting  point  and  a  second 
exposure  made.  The  plate  is  now  developed,  the  distance  between 
the  two  images  measured,  and  the  depth  calculated  (Fig.  3).     If, 


MANUAL  OF  SURGERY 


despite  the  use  of  these  or  similar  methods  of  locaHzation,  the  sur- 
geon tails  to  find  the  foreign  body,  it  may  be  extracted  with  the  aid 
of  the  fluoroscope.  However,  operating  in  a  dark  fluoroscopic 
room  is  inconvenient  and  not  without  danger  to  the  patient  and 
the  surgeon. 

The  X-ray  is  indicated  in  the  diagnosis  of  so  many  conditions, 
other  than  those  already  mentioned,  that,  in  order  to  avoid  repetition, 
we  must  refer  the  student  for  additional  informa- 
tion to  subsequent  pages,  particularly  those  deal- 
ing with  fractures,  dislocations,  bone  diseases,  sinus 
and  fistula,  the  lungs  and  pleural  cavity,  sub- 
phrenic abscess,  the  esophagus,  the  stomach,  the 
intestines,  and  the  kidney.  We  shall  there  call 
attention  to  some  of  the  methods  employed  to 
aid  in  the  differentiation  of  tissues  and  thus 
facilitate  radiographic  examinations,  e.g.,  the  in- 
troduction of  opaque  substances  into  sinuses,  the 
alimentary  canal,  and  the  urinary  apparatus,  and 
the  injection  of  gas  into  the  bladder,  ventricles  of 
the  brain,  subarachnoid  space,  and  peritoneal 
activity. 

The  therapeutic  effects  of  the  rays  may  be 
sh^doTofVe "foreign  classified  as  follows:  (i)  The  production  of  atro- 
body  and  are  }i  inch  p^^,  changes  in  the  appendages  of  the  skin;  (2)  the 

apart,    the   same  dis-   '^  .  .         ,  .  /    \      i. 

tance  as  the  shadows  destruction  of  organisms  m  the  tissues;  (3)  the 
ZX:naVo\S:tt  destruction  of  certain  pathological  tissues;  and 
positions  of  the  tube;   (4)  their  anodyne  effects,     (i)  In  hypertrichosis, 

S    corresponds  to  the  •       r  i  •      j  -j.   •      j      •      ui 

distance  of  the  target  sycosis,  favus,  and  tenia  tonsurans  it  is  desirable 
from  the  plate.    The  ^^  removc  the  hair.     Atrophy  and  decreased  f  unc- 

point  where  the  hnes  ^      "^ 

intersect  represents  tioual  activity  of  the  ScbaCCOUS  glands  are  in- 
foreign^  Vo^dy°^rlm  dicated  in  comedo  and  acne.  (2)  Though  the 
the   surface   next  to  j-^ys  apparently  have  no  effect  on  organisms  grow- 

the  plate.     (American    .  j      -j    j     n-      t 

Practice  of  Surgery.)  lug  upou  culture  media,  they  have  a  decided  enect 
upon  their  growth  when  in  the  living  tissues. 
Thus  tuberculous  ulcers  and  sinuses  and  those  due  to  ordinary 
pyogenic  organisms  may  dry  up  when  exposed  to  the  rays.  A 
similar  effect  is  produced  upon  diseases  due  to  mycehal  fungi, 
such  as  tenia  barbae,  tenia  tonsurans,  favus,  and  blastomycosis.  The 
destruction  of  these  organisms  is  probably  brought  about  by  tissue 
cells  stimulated  to  activity  by  the  rays.  (3)  Embryonic  and  glandular 
cells  are  most  susceptible  to  the  destructive  action  of  the  X-rays. 
In  inoperable  mahgnant  tumors,  which  are  composed  of  embryonic 


Fig.   3.- 


and 


DIAGNOSIS  19 

cells,  radiotherapy  is  often  of  decided  value  in  lessening  discharge, 
diminishing  fetor,  and  ameliorating  pain,  and  occasionally  the  growth 
shrinks  for  a  time.  The  only  form  of  malignant  disease  that  can  be 
cured  in  this  way  is  chronic  superficial  epithelioma,  and  even  in  this 
excision  is  quicker  and  safer. '  Some  surgeons  advise  radiotherapy 
after  all  operations  for  carcinoma  and  sarcoma,  to  prevent  recurrence. 
Fibroid  tumors  of  the  uterus,  keloids,  and  scars  also  may  be  influenced 
by  X-ray  treatment.  Owing  to  the  endarteritis  produced  by  the 
rays  angiomata  may  disappear,  and  chronic  bleeding,  e.g.,  from  the 
uterus,  be  brought  under  control.  Good  results  have  been  claimed 
for  this  agent  in  exophthalmic  goiter,  and  it  is  of  unquestionable 
value  in  enlarged  lymph  glands  from  any  cause,  as  well  as  in  spleno- 
medullary  leukemia.  (4)  As  an  anodyne  the  X-rays  have  been  used 
not  only  in  malignant  disease,  but  also  in  neuralgia  and  other  painful 
affections,  sometimes  with  excellent  results.  In  making  therapeutic 
applications  of  the  X-ray,  the  operator  should  always  protect 
the  healthy  parts  by  a  shield  of  lead,  and  when  the  rays  are  to  be 
projected  into  deep  structures  filters  of  leather  or  aluminium  should 
be  placed  between  the  tube  and  the  skin.  These  filters  absorb  the 
softer  rays,  thus  permitting  larger  doses  of  the  penetrating  rays 
without  irritating  the  skin. 

Untoward  Effects. — The  X-ray  burn  is  characterized  by  de- 
layed onset  and  remarkable  sluggishness  in  healing.  The  acute 
burn,  i.e.,  one  resulting  from  a  single  prolonged  exposure,  usually 
appears  on  the  second  or  third  day,  but  may  be  delayed  as  late  as 
the  fourteenth  day.  It  is  essentially  an  inflammatory  process,  ap- 
pearing at  first  much  like  the  erythema  of  sunburn,  and  like  sunburn 
leaves,  when  it  subsides,  a  pigmentation  of  the  skin,  which  is  more 
pronounced  in  those  of  dark  complexion.  If  subsidence  does  not 
occur  in  this  stage,  vesicles  and  blebs  develop  which  rupture  and 
expose  the  inflamed  corium;  occasionally  the  deeper  structures 
are  invaded,  and  extensive  sloughing  may  occur.  The  microscopic 
changes  are  those  of  degeneration  and  inflammation.  Chronic  burns 
occur  in  those  constantly  exposed  to  the  rays.  They  appear  slowly 
after  an  incubation  period  of  from  three  to  eleven  years.  The  clinical 
features  in  the  beginning  are  similar  to  those  of  acute  burns,  but  the 
red  color  changes  to  a  bronze  or  yellow,  the  nails  show  rugae  of  mal- 
nutrition, telangiectatic  spots  develop,  and  the  skin  becomes  glossy 
because  of  the  loss  of  glands  and  hair.  Cracks  and  hyperkeratoses 
appear  and  ulcers  form,  often  exposing  the  tendons  and  even  the 
bones,  and  occasionally  undergoing  epitheliomatous  degeneration. 
Porter  has  collected  47  cases  of  X-ray  carcinoma,  with  a  mortahty 


20  ilAXUAL  or  SURGERY 

of  25  per  cent.  The  skin  seems  to  be  easily  protected  by  the  ordinary 
clothing,  for  no  case  has  been  reported  except  upon  the  exposed 
surfaces.  At  the  present  time  the  operator  wears  leaded  gloves,  and 
stands  behind  a  screen  made  of  some  substance  impervious  to  the 
rays,  as  heavy  plate  glass,  sheet  iron,  or  lead.  If  heahng  does  not 
occur  after  the  usual  apphcations  for  ulcer,  an  X-ray  burn  may  be 
excised,  and  the  resulting  raw  surface  closed  by  a  plastic  operation  or 
covered  with  skin  grafts.  Prolonged  exposure  to  the  X-rays  may 
cause  steriHty  in  either  sex.  sometimes  transient,  sometimes  per- 
manent. Examination  of  the  blood  of  Rontgenologists  often  shows  a 
decrease  in  the  total  number  of  leukocytes  and  an  increase  in  the 
number  of  lymphocytes.  Sometimes  after  the  radiation  of  a  tumor 
or  other  lesion  there  is  a  general  reaction,  characterized  by  fever, 
and  supposed  to  be  due  to  toxemia  from  the  ab-orption  of  the  prod- 
ucts of  cellular  degeneration. 

Radium  and  certain  other  mineral  substances  (uranium,  thorium, 
polonium)  emit  rays  similar  to,  if  not  identical  with,  the  X-rays. 
Radium  bromid  is  the  material  usually  employed  for  therapeutic 
purposes.  It  is  kept  in  a  hermetically  sealed  glass  tube,  which  may 
be  applied  to  a  surface  lesion,  or  buried  in  the  tissues  after  making  an 
incision.  Exposures  last  from  one  to  many  hours.  Radium  therapy 
has  been  tried  in  the  same  diseases  that  are  treated  by  the  X-ray. 
The  time  is  not  yet  ripe  for  passing  judgment  on  the  value  of  this 
agent.  Its  rays  seem  to  have  greater  penetrating  power  than  the 
X-rays,  and  some  beheve  they  have  a  specific  action  not  possessed 
by  the  X-rays.  The  chief  objections  to  the  use  of  radium  are  its 
enormous  expense  and  the  difficulty  in  obtaining  a  pure  sample. 


CHAPTER  II 
ANESTHESIA 

Surgical  anesthesia  means  loss  of  sensation  produced  by  certain 
agents,  which  are  called  anesthetics. 

GENERAL  ANESTHESIA  is  associated  with  unconsciousness, 
and  is  indicated  to  abolish  pain  during  surgical  operations,  renal 
colic,  etc.;  to  control  convulsive  seizures;  to  secure  muscular  relaxation 
in  order  to  make  a  diagnosis,  to  facilitate  operative  manipulations, 
especially  in  the  abdomen,  or  to  carry  out  such  treatment  as  reduc- 
tion of  a  hernia,  a  fractured  bone,  or  a  dislocated  joint;  and  to  abolish 
volition  in  order  to  detect  a  malingerer.  Except  for  the  purpose  of 
saving  life,  it  is  contraindicated  in  profound  shock,  great  exhaustion, 
and  in  acute  or  advanced  renal,  circulatory,  or  pulmonary  disease. 
The  general  anesthetics  most  frequently  employed  are,  in  the  order 
of  their  safety,  nitrous  oxid  (one  death  in  300,000),  ether  (one  death 
in  15,000),  ethyl  chlorid  (one  death  in  12,000),  and  chloroform  (one 
death  in  3,000). 

The  choice  of  a  general  anesthetic  depends  principally  upon  the 
cc)ndition  of  the  patient  and  the  character  of  the  operation. 

Ether  is  the  best  and  least  dangerous  general  anesthetic  in  the 
hands  of  one  with  little  experience,  likewise  in  the  hands  of  the 
specialist  in  anesthesia  when,  as  is  the  case  in  most  of  the  major 
operations  of  surgery,  the  patient  is  to  be  completely  relaxed,  hence, 
under  these  circumstances,  it  should  always  be  employed  unless  there 
are  distinct  contraindications.  The  most  important  contraindica- 
tions to  ether  are  (i)  inflammation  of  some  portion  of  the  respiratory 
apparatus,  because  of  the  irritating  action  of  the  drug  on  mucous 
membranes,  and  (2)  the  presence  of  fire  in  an  open  grate  or  stove, 
which  may  ignite  the  ether.  Since  ether  vapor  is  heavier  than  air 
and  descends,  the  danger  of  an  exposed  artificial  light  is  obviated  by 
placing  the  light  several  feet  above  the  level  of  the  patient's  head. 
The  actual  cautery  may  be  used  in  the  region  of  the  mouth,  if  the 
precaution  is  first  taken  to  remove  the  anesthetic  and  fan  away  the 
fumes.  Of  secondary  importance,  and  by  no  means  absolute,  are 
(3)  marked  arteriosclerosis,  which  predisposes  to  vascular  rupture 
during  the  struggling  incident  to  etherization;  (4)  disease  of  the  kid- 
neys (many  authors  believe  chloroform  to  be  more  irritating  to  the 
kidneys    than    ether;    in    these    cases    nitrous   oxid  and  oxygen^or 

21 


22  MANUAL  OF  SURGERY 

local  anesthesia  should  be  employed  whenever  possible) ;  and  (5) 
operations  about  the  nose  or  mouth,  in  which  the  anesthetic  can  be 
applied  intermittently  only,  and  in  which  chloroform,  being  more 
powerful,  will  better  maintain  anesthesia;  this  contraindication 
ceases  to  exist  if  one  of  the  insufflation  methods  is  employed. 

Chloroform  secures  complete  muscular  relaxation,  and  does  not 
cause  the  veins  to  distend  hke  ether,  hence  makes  bleeding  less 
annoying;  it  is  also  quicker  in  its  action,  more  agreeable  to  the 
patient,  and  more  convenient  to  the  anesthetist  and  operator,  espe- 
cially in  operations  about  the  head,  face,  and  neck;  but  these  ad- 
vantages are  overbalanced  by  its  increased  danger.  Chloroform 
is  no  safer  in  children  or  during  pregnancy  than  at  any  other  time. 
It  is  preferable  in  military  surgery,  because  it  economizes  space  and 
time,  and  is  generally  employed  in  the  tropics,  owing  to  the  great 
volatility  of  ether.  In  diseases  of  the  liver  and  in  diabetes  chloro- 
form is  absolutely  contraindicated.  In  the  latter  nitrous  oxid  mixed 
with  oxygen  is  the  safest  general  anesthetic;  ether,  however,  must 
be  employed  if  muscular  relaxation  is  mandatory. 

Nitrous  oxid  is  by  far  the  safest  anesthetic  for  brief  operations 
(from  two  to  five  minutes)  in  which  muscular  relaxation  is  not  de- 
sired, such  as  the  extraction  of  a  tooth  or  the  incision  of  an  abscess. 
For  longer  operations  in  which  muscular  relaxation  is  not  important, 
nitrous  oxid  combined  with  oxygen  or  with  atmospheric  air  is  the 
safest  anesthetic.  It  is  particularly  indicated  in  diabetes  and 
nephritis.  It  is  contraindicated  when  the  heart  or  the  arteries  are 
seriously  affected,  when  there  is  mechanical  obstruction  of  the  air 
passages,  when  the  patient  is  under  five  years  of  age  (owing  to  the 
ease  with  which  infants  are  asphyxiated) ,  and  when  the  anesthetizer 
is  unskilled.  Muscular  adults  addicted  to  the  excessive  use  of  alco- 
hol and  tobacco  are  bad  subjects  for  nitrous  oxid,  indeed  for  any 
anesthetic.  Among  the  disadvantages  attending  the  administration 
of  nitrous  oxid  must  be  mentioned  its  great  expense,  the  necessity  for 
cumbersome  and  complicated  apparatus,  and  the  marked  increase  in 
venous  congestion,  the  last  constituting  a  decided  objection  in  many 
operations. 

Ethyl  chlorid  is  often  used  as  a  substitute  for  nitrous  oxid  in  brief 
operations  and  as  a  preliminary  to  ether.  As  it  is  25  times  more 
dangerous  than  nitrous  oxid,  however,  we  believe  it  should  never  be 
employed . 

The  preparation  for  anesthesia  is  combined  with  that  of  the 
operation  itself  (see  "Surgical  Technic")-  One  should  examine  the 
heart,  blood  vessels,  lungs,  urine,  nose,  throat,  mouth,  and  in  many 


ANESTHESIA  23 

cases  the  blood.  The  bowels  should  be  moved  by  a  laxative,  and 
on  the  morning  of  the  operation  by  an  enema.  In  the  feeble  and 
exhausted  purgation  should  be  avoided,  and  stimulating  or  nutri- 
tive enemas  continued  until  within  a  few  hours  of  the  operation. 
No  solid  food  should  be  given  on  the  day  of  operation,  although  a  cup 
of  tea,  coiYee,  or  consomme  may  be  given  not  less  than  six  hours 
before  the  time  of  anesthesia.  Just  before  administering  the  anes- 
thetic the  patient  should  pass  urine,  or,  if  necessary,  be  catheterized. 
If  a  woman,  hair-pins  should  be  removed  and  the  hair  braided 
and  done  up  in  a  cap  or  towel.  Artificial  teeth  or  other  foreign 
bodies  should  be  removed  from  the  mouth,  the  lips  and  nostrils 
greased,  especially  if  chloroform  is  to  be  used,  and,  to  prevent  con- 
junctivitis from  chloroform  or  ether  vapor,  a  drop  of  liquid  petrola- 
tum instilled  into  each  conjunctival  sac.  The  patient  should  be 
protected  from  cold,  and  jewelry  of  various  kinds  should  be  put 
away  in  a  safe  place.  In  emergency  cases,  if  the  patient's  stomach  is 
full,  and  especially  in  intestinal  obstruction,  gastric  lavage  should  be 
performed  previous  to  the  administration  of  the  anesthetic,  in  order 
to  prevent  sudden  death  from  inundation  of  the  lungs  with  vomited 
matter.  In  these  cases  an  enema  may  or  may  not  be  given,  accord- 
ing to  the  character  of  the  operation,  but  in  all  a  complete  examina- 
tion should  be  made.  A  patient  should  never  be  anesthetized 
wdthout  removing  the  shoes  and  without  making  sure  that  all  cloth- 
ing about  the  neck,  chest,  and  abdomen  is  loose;  corsets  always  should 
be  removed.  With  the  possible  exception  of  nitrous  oxid,  a  patient 
should  never  be  anesthetized  in  the  sitting  posture. 

The  anesthetist  should  ascertain  whether  the  patient  has  pre- 
viously taken  an  anesthetic,  and  whether  addicted  to  the  use  of  alco- 
hol or  other  drugs.  He  should  know  the  results  of  the  urinalysis, 
listen  to  the  heart  and  lungs,  study  the  pulse,  note  the  color  of  the 
skin  and  mucous  membranes,  and  assure  himself  that  the  mouth  is 
free  of  foreign  bodies.  His  hands  should  be  clean,  and  in  operations 
on  the  head  and  neck  they  should  be  sterilized.  He  should  wear  a 
sterile  gown  and  cap.  In  addition  to  the  anesthetic  and  inhaler  one 
should  provide  himself  with  a  mouth-gag,  tongue  forceps,  a  pair  of 
hemostats  with  gauze  sponges  for  swabbing  out  the  pharynx,  a  hypo- 
dermic syringe  with  strychnin  and  atropin,  and  a  tracheotomy  tube. 
It  is  desirable  to  have  also  a  solution  of  boric  acid  for  the  eyes  in  case 
they  become  irritated,  and  in  some  instances  oxygen  may  be  needed. 
A  third  person  should  always  be  present  to  assist,  if  necessary,  in 
restraining  the  patient  and  to  act  as  a  witness,  as  unjust  accusations 
are  occasionally  made  against  the  anesthetizer,  especially  by  females. 


24 


MANUAL    OF    SURGERY 


The  administration  of  ether  by  inhalation  is  rendered  less  terrify- 
ing to  the  patient,  and,  it  is  said,  actually  less  dangerous,  if  three  or 
four  drops  of  a  25  per  cent,  solution  of  oil  of  bitter  orange  peel  in 
alcohol  (75  per  cent.)  is  placed  on  the  mask  a  few  minutes  before 
adding  the  anesthetic.  It  is  supposed  that  oil  of  orange,  by  dulhng 
the  sense  of  smell  to  the  irritating  fumes  of  ether,  prevents  harmful 
reflex  stimulation  of  the  pneumogastric  nerve.  One  of  three  methods 
of  etherization  by  inhalation  may  be  employed.  In  the  open  method, 
which  is  very  slow,  the  ether  is  inhaled  from  a  folded  towel,  held  over 
the  patient's  nose  and  mouth  in  such  a  way  as  not  to  exclude  the  air. 
The  closed  method,  in  which  the  air  is  decidedly  restricted,  and  in 
which  the  expiratory  products  are  retained  and  rebreathed,  is  quick, 
and  warms,  moistens,  and  economizes  the  ether,  but  is  more  dan- 
gerous than  either  of  the  other  methods.  Some  anesthetists  main- 
tain, however,  that  rebreathing,  with  all  forms  of  inhalation  anes- 
thetics, is  physiologically  advanta- 
geous. Those  who  use  the  closed 
method  find  the  Clover  inhaler 
satisfactory.  It  consists  of  a 
dome-shaped  ether  reservoir  sur- 
rounded by  a  water  chamber, 
which  maintains  the  ether  at  the 
proper  temperature  for  evapora- 
tion. A  fenestrated  metal  tube 
runs  through  the  reservoir  from  a 
large  rubber  bag  to  the  face  piece. 
By  rotating  the  reservoir  varying  quantities  of  vapor  escape  into 
the  rubber  bag,  from  which  it  is  breathed  backward  and  forward 
with  the  expiratory  products;  fresh  air  may  be  admitted  from 
time  to  time  by  raising  the  face  piece.  The  semiopcn  method,  in 
which  the  entrance  of  air  is  slightly  limited,  but  in  which  the  ex- 
piratory products  are  not  retained,  is  the  one  commonly  employed. 
An  inhaler  may  be  improvised  by  rolHng  a  folded  towel  or  a  piece 
of  gauze  into  the  shape  of  a  cone.  The  Alhs  inhaler  (Fig.  4)  con- 
sists of  a  cyhndrical  metal  frame  with  shts  in  the  sides,  through 
which  a  flannel  bandage  is  threaded  backwards  and  forwards.  This 
is  enclosed  in  a  metal  case  or  folded  towel  which  projects  beyond 
the  frame  and  is  fitted  to  the  patient's  face.  The  inhaler  is  placed 
over  the  patient's  nose  and  mouth,  and  after  several  breaths  have 
been  taken  to  lessen  fright,  the  ether  is  applied  drop  by  drop  until  the 
patient  is  anesthetized,  the  intervals  between  the  drops  becoming 
shorter  as   the  patient   becomes  accustomed   to   the  vapor.     The 


Pig.   4. — Allis'  Inhaler. 


ANESTHESIA 


25 


administration  should  be  uninterrupted  and  as  nearly  uniform  as 
possible.  During  the  first  stage  of  anesthesia,  which  ends  with  the 
loss  of  consciousness,  the  pulse  is  accelerated,  the  pupils  large  and 
mobile,  and  a  rather  pleasant  feeling  of  drowsiness,  and  tingling 
in  the  extremities,  is  experienced.  Many  patients  breathe  deeply, 
others  hold  their  breath;  in  the  latter  instance  all  that  need  be  done 
is  to  remove  the  cone  for  a  moment.  Cough  is  rarely  annoying  if  the 
drop  method  be  employed.  With  the  onset  of  unconsciousness  there 
is  a  short  period  of  analgesia  (primary  anesthesia),  during  which 
brief  operations  may  be  performed.  The  second  stage,  or  the  stage  of 
excitement,  extends  from  the  loss  of  consciousness  to  the  loss  of 
reflexes.  Memory,  volition, 
and  intelligence  are  abolished, 
while  laughing,  shouting,  and 
struggling  may  occur.  Slight 
movements  of  the  extremities 
should  not  be  restrained  un- 
less they  interfere  with  the 
anesthetist,  as  such  often 
evokes  greater  struggling. 
The  pulse  is  rapid,  the  pupils 
are  dilated  and  react  to  light, 
and  the  muscles  may  be  rigid 
or  thrown  into  clonic  contrac- 
tions.    At    this    time    the        ^  ,.       .  .  x-        , 

riG.    5. —  Vaporizing  apparatus.      Note  that 

breathing    may    be     irregular     the  ether  reservoir  is  only  half  filled  and  that  the 

,  •]  A    A       ^^'^S  tube  in  it  is  attached  to  the  pump;  if  the 

or      temporarily      SUSpenaea.     short  tube  were  connected  with  the  pump,  liquid 

The  face  is  congested,    some-     ether  would  be  driven  from  the  reservoir.     Even 

when  the  tubes  are  properly  arranged,  a  spray 
times      cyanotic,      and     often     of  ether  may  be  forced  from  the  reservoir,  hence 
covered      with      perspiration,     ^he   small   bottle  on  the  left,   which  acts  as  a 
^       ^  condenser. 

More  or   less   frothy   mucus 

is  present  in  the  mouth  and  throat,  and  sometimes  it  becomes  exces- 
sive. During  the  third  stage  the  breathing  is  deep  and  audible,  the 
pulse  full  and  regular,  the  muscles  relaxed,  and  the  corneal  reflex 
abolished.  Touching  the  cornea  with  the  finger,  however,  may  pro- 
duce irritation,  and  it  is  much  better  simply  to  separate  the  lids 
and  notice  the  presence  or  absence  of  flaccidity.  The  pupils  are  of 
moderate  size  and  react  to  light.  Dilated  pupils  failing  to  react  to 
light  indicate  a  dangerous  degree  of  anesthesia.  During  this  stage 
a  transient  roseolous  rash  may  be  noticed. 

Insufflation  of  ether  into  the  mouth,  nose,  or  pharynx  is  indi- 
cated particularly  in  operations  about  the  head.  face,  mouth,  and 


26  MANUAL  OF  SURGERY 

neck,  since  it  removes  the  anesthetizer  from  the  field  of  operation  and 
permits  an  uninterrupted  administration  of  the  anesthetic.  Anes- 
thesia is  induced  by  one  of  the  foregoing  methods  and  maintained  by 
a  vaporizing  apparatus  (Fig.  5).  By  means  of  a  hand  bulb,  a  foot 
pump,  or  an  electric  blower,  air  is  forced  through  a  bottle  of  ether, 
which  is  placed  in  a  can  of  water  at  a  temperature  of  98°  F.  The 
ether  vapor,  thus  warmed,  an  important  matter  according  to  recent 
investigations,  passes  through  an  empty  bottle,  which  acts  as  a 
condenser,  to  the  outlet  tube.  The  outlet  tube  is  connected  by  soft 
rubber  tubing  with  a  curved  metal  or  hard  rubber  tube  which  is 
hooked  in  the  nostril  or  angle  of  the  mouth,  or  with  a  catheter  which 
passes  back  through  the  nostril  to  the  level  of  the  soft  palate.  Intra- 
pharyngeal  insufflation  economizes  ether,  facilitates  breathing,  and 
causes  less  cyanosis  and  postanesthetic  vomiting  than  the  ordinary 
inhalation  methods;  free  exit  should  be  provided  for  the  superfluous 
vapor  by  keeping  the  mouth  open,  or  by  inserting  a  tube  in  the 
opposite  nostril. 

Intratracheal  insufllation  of  ether  (Meltzer-Auer)  has  supplanted 
the  various  forms  of  apparatus  designed  to  prevent  collapse  of  the 
lungs  during  intrathoracic  operations,  since  it  not  only  obviates  the 
danger  of  pneumothorax  but  automatically  ventilates  the  lungs. 
It  keeps  the  anesthetizer  out  of  the  way,  eliminates  the  possibility 
of  obstruction  of  the  air  passages,  prevents  the  inhalation  of  blood, 
mucus,  vomitus,  and  other  deleterious  substances,  and,  owing  to  the 
absence  of  cyanosis,  lessens  venous  hemorrhage;  hence  is  it  of  great 
value  in  operations  about  the  mouth  and  pharynx,  in  operations  for 
intestinal  obstruction  in  which  fluid  is  constantly  regurgitated  from 
the  stomach,  in  operations  for  goiter  and  similar  conditions  in  which 
the  trachea  is  displaced  or  distorted,  and  in  operations  in  which  the 
patient  must  lie  face  downwards.  According  to  Peck  the  rehef  of  all 
strain  upon  the  respiratory  apparatus  and  consequently  the  relief 
of  much  strain  upon  the  heart  and  central  nervous  system  is  one  of 
the  most  valuable  features  of  the  method.  "  Overetherization  is 
impossible."  In  cases  of  apnea  from  opium  poisoning,  etc.,  air,  or 
air  mixed  with  oxygen,  can  be  blown  into  the  trachea,  thus  maintain- 
ing aeration  of  the  blood  until  spontaneous  respiration  returns.  We 
have  employed  intratracheal  insufflation  of  ether  in  many  cases,  and 
feel  that  its  merits  have  not  been  overstated.  The  patient  is  first 
etherized  in  the  usual  way;  then,  with  the  aid  of  a  Jackson  laryngo- 
scope, a  silk  elastic  catheter  is  inserted  into  the  trachea  to  a  point 
just  short  of  its  bifurcation.  In  addition  to  the  noise  produced  by 
the  breath  passing  through  the  catheter,  one  may  be  sure  it  is  in  the 


ANESTHESIA  "  T /2l7, 

trachea,  unless  there  is  a  stricture  or  a  diNcrticulum  of  the  esophagus, 
by  i)ushin<j!;  the  catheter  onwards  until  it  meets  the  resistance  offered 
by  the  smaller  bronchi.  If  more  than  35  cm.  of  the  catheter  can  be 
introduced  it  is  in  the  esophagus,  in  which  event  the  ether  will  enter 
and  distend  the  stomach.  The  catheter  should  be  about  half  the 
length  of  the  glottis  in  diameter,  i.e.,  about  24  F.  for  the  average 
adult,  and  correspondingly  smaller  for  children.  It  should  have  two 
marks  on  it,  one  j^  cm.  and  one  26  cm.  from  the  tip.  When  the  latter 
mark  is  opposite  the  teeth  the  first  mark  is  opposite  the  glottis,  and 
the  tip  5  cm.  above  the  bifurcation  of  the  trachea.  The  tube  is  held 
in  place  with  a  special  clip,  or  fastened  to  the  cheek  with  adhesive 
plaster,  and  then  connected  with  the  insufflation  apparatus.  The 
apparatus  devised  by  Elsberg  or  a  simpler  home-made  contrivance 
may  be  employed.  The  air  is  driven  by  foot  bellows  (or  an  electric 
blower,  in  which  case  an  oil  filter  is  needed)  through  a  wash  bottle 
containing  hot  water,  thus  filtering,  warming,  and  moistening  the  air, 
which  is  then  delivered  to  a  bifurcated  tube,  one  branch  of  which 
passes  directly  to  the  tube  connected  with  the  catheter  and  the  other 
to  the  ether  reservoir,  the  ether  reservoir  having  another  tube  on  its 
opposite  side  joining  the  tube  connected  with  the  catheter.  By 
manipulating  clamps  or  stop-cocks  on  these  branches  the  patient 
may  receive  pure  air,  pure  ether  vapor,  or  a  mixture  of  air  and  ether. 
In  the  Elsberg  apparatus  the  percentage  of  ether  and  air  is  regulated 
by  a  hand  wheel  which  is  connected  with  an  indicator.  The  tube 
leading  to  the  catheter  is  connected  with  a  manometer,  which 
records  the  pressure  of  the  air  current  passing  through  it.  The 
average  pressure  during  anesthesia  should  be  20  mm.,  but,  if  indi- 
cated, it  can  be  increased  to  40  or  even  50  mm.  Every  minute  or 
two,  however,  the  pressure  should  be  reduced  to  zero  for  an  instant, 
to  allow  the  lungs  to  deflate.  The  percentage  of  ether  needed  varies 
with  the  patient,  half  ether  and  half  air  probably  being  the  average. 
If  cyanosis  occurs,  it  means  that  the  tube  has  been  pushed  into  one 
of  the  smaller  bronchi,  that  it  is  not  far  enough  in  the  trachea,  or  that 
too  large  a  tube  has  been  introduced.  At  the  end  of  the  operation 
quick  recovery  from  the  anesthetic  can  be  secured  by  insufflating 
pure  air,  thus  blowing  the  ether  from  the  lungs.  At  this  time,  indeed 
at  any  time,  if  the  patient  is  not  completely  under  the  influence  of  the 
anesthetic,  a  mouth  gag  should  be  kept  between  the  teeth,  else  the 
catheter  may  be  bitten  off.  Hoarseness  and  pulmonary  complica- 
tions are  not  produced  by  insufflation  anesthesia,  post-anesthetic 
vomiting  is  less  common  than  after  other  methods,  and  shock  from 
operation  seems  to  be  less  marked  (Peck  and  Elsberg). 


28  MANUAL  OF  SURGERY 

Intratracheal  insufflation  of  nitrous  oxid  and  oxygen,  after  pre- 
liminary etherization,  has  been  tried  by  Cotton,  Boothby  and  others. 

Intravenous  administration  of  ether  (Burckhardt)  is  not  recom- 
mended. It  may  cause  thrombosis  and  embolism,  nephritis,  hemo- 
globinuria, and,  owing  to  the  large  amount  of  fluid  injected,  it  in- 
creases the  strain  on  the  heart,  and  markedly  augments  the  bleeding, 
even  from  the  smallest  vessels.  It  is  especially  dangerous  in  patients 
with  vascular  disease  or  a  high  blood  pressure.  Kiimmel  and  others, 
however,  advocate  this  method  of  etherization  in  cases  in  which 
intravenous  infusion  of  salt  solution  is  beneficial,  e.g.,  in  intra- 
abdominal bleeding  and  gastrectomy  for  carcinoma.  Normal  salt 
solution  at  a  temperature  of  85°F.  (ether  boils  at  96°)  containing  5  per 
cent,  of  ether  is  allowed  to  run  slowly  into  a  vein  of  the  arm,  the  tech- 
nic  being  identical  with  that  for  the  infusion  of  salt  solution.  Con- 
nected with  the  cannula,  however,  is  a  second  tube  which  leads  from 
a  reservoir  containing  salt  solution  without  ether,  so  that  when 
the  stream  of  ether  is  interrupted  the  salt  solution  can  be  turned  on, 
thus  lessening  the  danger  of  clotting  in  the  vein.  In  from  five  to  ten 
minutes  after  beginning  the  injection  the  patient  is  ready  for  opera- 
tion. Kiimmel's  longest  anesthesia  extended  over  two  hours,  during 
which  time  1,700  cc.  of  the  mixture  (corresponding  to  85  grammes  of 
ether)  were  injected. 

Chloral,  veronal,  hedonal,  isopral,  and  paraldehyd  likewise  have 
been  administered  intravenously  for  the  production  of  general  anes- 
thesia, but  are  more  dangerous  than  ether. 

Rectal  etherization  has  been  employed  in  operations  about  the 
upper  respiratory  passages.  A  bottle  of  ether  to  which  a  rubber 
rectal  tube  is  attached  is  placed  in  water  at  a  temperature  of  i2o°F., 
or  the  ether  vapor  may  be  forced  into  the  rectum  by  means  of  the 
vaporizer  shown  in  Fig.  5,  a  rectal  tube  being  substituted  for  the 
mouth  piece.  The  disadvantages  of  the  method  are  the  greater 
time  necessary  to  induce  anesthesia,  and  the  unpleasant  sequelae,  such 
as  prolonged  stupor,  meteorism,  and  bloody  diarrhea. 

The  administration  of  chloroform  requires  more  skill  and  care 
than  etherization.  A  preliminary  hypodermic  injection  of  atropin  is 
advisable,  as  this  drug  prevents  reflex  inhibition  of  the  heart,  owing 
to  its  depressing  effect  on  the  pneumogastric  nerves.  The  chloroform 
may  be  inhaled  from  a  handkerchief  or  a  piece  of  gauze,  but  a  spe- 
cial mask,  such  as  the  Skinner  or  Esmarch  (Fig.  6),  each  of  which 
consists  of  a  wire  frame  covered  with  one  layer  of  flannel,  is  more 
convenient.  The  inhaler  is  held  just  over  the  nose  and  mouth  and 
the  chloroform  dropped  on  it.     The  average  adult  patient  will  require 


ANESTHESIA  29 

one  drop  of  chloroform  every  four  or  six  seconds  to  maintain  anes- 
thesia. The  vapor  should  always  be  liberally  mixed  with  air;  liquid 
chloroform  should  never  be  allowed  to  touch  the  skin,  as  it  may  pro- 
duce blistering.  The  phenomena  of  chloroform  anesthesia  are  in  the 
main  similar  to  those  of  ether.  The  first  and  second  stages  are  shorter, 
the  vapor  is  more  pleasant,  and  being  less  irritating  than  ether, 
less  mucus  is  secreted.  An  excess  of  chloroform  causes  the  pa- 
tient to  hold  his  breath,  and  if  the  inhaler  is  not  withdrawn  at  this 
time,  the  patient  may  take  a  deep  inspiration  and  get  an  overdose. 
This  accident  has  resulted  in  death,  and  should  be  recalled  when 
chloroforming  crying  children,  and  when  a  surgeon  attempts  to 
operate  before  the  third  stage  is  reached,  thus  causing  the  patient  to 
breathe  deeply.  During  the  stage  of  muscular  excitement,  which  is 
less  marked  than  with  ether,  the  respirations  should  be  watched  with 
great  care.  Chloroform  vapor  is  not  inflammable,  but  in  the  pres- 
ence of  a  naked  liame  gives  off  irritating  products  (phosgene  and 
hydrochloric  acid),  which,  in  a  small  room,  may  cause  irritation  of  the 
eyes  and  respiratory  passages. 
The  third  stage  is  characterized  by 
quiet  respirations  which  are  often 
difficult  to  appreciate.  The  pulse 
is  sluggish  and  feeble  in  contrast  to 
the  full  and  rapid  pulse  of  ether. 
The  pupil  is  moderatelv  contracted  ^  ^         ,  , ,    , 

Fig.  6. — Esmarch  Mask. 

unless  the  anesthesia  is  profound, 

when  it  dilates.  As^  with  ether,  dilated  pupils,  faihng  to  react  to 
Hght,  indicate  a  dangerous  degree  of  anesthesia.  Throughout  the 
anesthesia  the  pulse  and  repirations  should  be  carefully  watched. 
The  character  of  the  respirations  may  be  determined  by  listening  to 
them,  by  observing  the  movements  of  the  chest  and  abdomen,  and 
by  noting  the  patient's  color.     The  pulse  may  be  felt  at  the  temple. 

Oxygen  combined  with  ether  or  chloroform  tends  to  prevent 
spasm  of  the  respiratory  muscles  and  cyanosis.  That  it  lessens  irri- 
tation of  the  kidneys  and  post-anesthetic  vomiting  is  doubtful.  The 
oxygen,  after  bubbling  through  the  anesthetic,  is  conveyed  to  the 
face  piece  through  a  rubber  tube.  It  may  be  given  also  by  placing 
the  end  of  the  oxygen  tube  in  or  beneath  the  inhaler. 

Nitrous  oxid  comes  in  steel  cyhnders,  in  which  it  has  been  hquefied 
by  pressure.  It  is  allowed  to  escape  as  vapor  into  a  rubber  bag  from 
which  it  passes  through  a  tube  to  a  face  piece.  A  piece  of  cork,  rub- 
ber or  wood;  to  which  a  string  is  attached,  so  that  it  cannot  be 
swallowed,  is  placed  between  the  molar  teeth,  and  the  face  piece 


3°  MANUAL  OF  SURGERY 

adjusted.  The  gas  is  then  turned  on.  The  patient  becomes  cyanotic, 
the  pupils  dilate,  and  squint  is  often  seen.  With  the  onset  of  un- 
consciousness, which  is  usually  complete  in  about  one  minute,  the 
breathing  becomes  stertorous  and  muscular  twitchings  are  observed. 
The  duration  of  complete  anesthesia  is  about  one  minute.  The 
pulse  and  respirations  should  be  carefully  watched.  Nitrous  oxid 
is  often  used  to  induce  anesthesia,  which  is  then  continued  by  ether, 
with  the  object  of  reducing  the  period  of  narcosis,  the  amount  of 
ether  used,  and  the  unpleasantness  of  the  early  stages  of  ether  anes- 
thesia. Anesthesia  may  be  induced  with  an  ordinary  nitrous-oxid 
apparatus  and  etherization  begun  with  an  ordinary  inhaler. 
Much  better  is  an  apparatus  which  allows  the  gradual  adminis- 
tration of  ether  before  the  nitrous  oxid  is  discontinued.  Hew- 
itt uses  a  Clover's  inhaler  to  which  is  attached  a  charged  gas-bag 
holding  about  two  gallons  of  gas.  By  means  of  a  stop-cock  the 
patient  is  allowed  to  breathe  about  one-half  the  nitrous  oxid,  the 
remaining  half  being  breathed  backwards  and  forwards  during 
the  gradual  admission  of  the  ether.  Nitrous  oxid  anesthesia  may  be 
prolonged  by  mixing  the  gas  with  atmospheric  air,  or  by  combining 
it  with  oxygen.  The  latter  method  is  the  safer  and  may  be  employed 
in  operations  of  any  length,  provided  muscular  relaxation  is  not 
necessary.  For  the  administration  of  nitrous  oxid  and  oxygen 
Hewitt  employs  an  apparatus  consisting  of  two  steel  cylinders 
containing  the  respective  gases;  these  communicate  with  two  bags 
which  are  connected  with  the  mixing  chamber,  to  which  the  mouth 
piece  is  attached.  By  means  of  a  regulator  the  percentage  of  oxygen, 
which  at  the  beginning  of  the  administration  should  be  2  or  3  percent., 
is  increased  progressively  to  8  or  10  per  cent.  The  longer  the  duration 
of  the  anesthesia,  the  greater  the  amount  of  oxygen  required.  In 
anemia  and  toxemia  the  quantity  of  oxygen  may,  in  some  cases,  be 
increased  to  20  per  cent.,  owing  to  the  diminished  oxygen-carrying 
capacity  of  the  blood.  Many  anesthetizers  have  an  ether  chamber 
connected  with  the  apparatus,  in  order  to  secure,  when  desired,  at  least 
partial  relaxation.  The  addition  of  ether  is  demanded  in  from  10  to 
25  per  cent,  of  major  operations.  A  preliminary  hypodermic  injec- 
tion of  morphin  and  atropin  also  tends  to  minimize  muscular  rigidity 
and  is  almost  a  routine  practice  with  hose  who  give  nitrous  oxid  and 
oxygen. 

Ethyl  chlorid,  like  ether,  is  highly  inflammable,  and  is  easily  ad- 
ministered without  special  apparatus.  Because  of  the  increased 
danger  it  should  not  be  given  with  a  closed  inhaler.  Spraying  it  upon 
two  layers  of  gauze  placed  over  the  nose  and  mouth  is  the  safest 


ANESTHESIA  3 1 

method  of  administration.  Ten  cc.  are  usually  sufficient  for  this 
purpose.  Anesthesia  is  induced  in  from  one-half  to  two  minutes; 
the  patient  rapidly  recovers,  usually  without  vomiting  or  other 
disagreeable  phenomena.     See  also  "Local  Anesthesia." 

Ethyl  bromid  is  somewhat  similar  in  its  elTects  to  ethyl  chlorid, 
and  may  be  used  for  the  same  purposes,  but  is  less  safe.  It  may  be 
given  from  a  closed  mask  or  from  a  towel.  The  entire  dose  of  from 
15  to  30  grams  is  poured  into  the  cone  at  once  and  all  air  excluded. 
Narcosis  is  quickly  induced  and  recovery  rapidly  follows.  Ethyl 
bromid  is  a  cardiac  depressant,  and  is  contraindicated  in  children,  in 
the  weak  and  anemic,  and  in  those  suffering  from  cardiac  disease, 
alcoholism,  and  kidney  affections. 

Anesthetic  mixtures  containing  chloroform,  the  best  known  of 
which  is  the  A.  C.  E.  mixture  (alcohol  i,  chloroform  2,  ether  3),  should 
rarely  or  never  be  employed.  That  they  possess  advantages  over 
ether  is  doubtful,  that  they  are  more  dangerous  is  positive.  Many 
operators  prefer  to  give  gr.  l-g  to  1^  of  morphin  hypodermatically  a 
short  time  before  beginning  the  anesthesia,  to  shorten  the  preliminary 
stages,  make  them  more  pleasant,  and  to  obviate  fear,  Hmit  the 
amount  of  anesthetic  necessary,  and  prevent  shock.  The  objections 
to  administering  morphin  are  that  it  makes  the  pupillary  reaction,  one 
of  the  most  valuable  guides  in  anesthesia,  untrustworthy;  interferes 
withthe  expulsion  of  mucus,  blood,  or  other  material  from  the  air  pas- 
sages; depresses  respiration,  thus  delaying  the  ehmination  of  the  anes- 
thetic after  operation;  and  that  it  not  infrequently  causes  vomiting. 
The  practice  should  not  be  a  routine  one,  but  in  certain  cases,  such  as 
morphin  or  alcoholic  habitues,  it  may  be  advantageous.  Hyoscin  or 
atropin  is  sometimes  given  just  before  ether  in  order  to  lessen  the 
amount  of  mucus  secreted.  Scopolamin-morpliin  anesthesia  is 
dangerous,  and  cannot  be  recommended.  One  milhgramme  of 
scopolamin  (hyoscin),  and  25  miUigrammes  of  morphin  are  divided 
into  three  doses,  which  are  injected  hypodermically  23^^,  i3-^  and  }A 
hour  before  operation  (Korff).  The  patient  falls  into  a  sound  sleep 
which  lasts  for  live  or  six  hours  after  the  last  injection.  Inhalations 
of  chloroform  or  ether  may  be  necessary. 

Anociassociation  is  a  term  invented  by  Crile  to  designate  a  condi- 
tion in  which,  according  to  his  theory,  all  noxious  influences  attending 
anesthesia  for  operation  are  eliminated.  Fear  is  aboHshed  by  a 
prehminary  hypodermic  injection  of  morphin  and  scopolamin;  the 
patient  is  anesthetized  with  nitrous  oxid  and  oxygen,  combined,  if 
necessary,  with  ether;  and,  "as  all  inhalation  anesthesia  puts  asleep 
only  a  portion  of  the  brain,"  novocain  or  other  local  anesthetic  is 


32  MANUAL  OF  SURGERY 

injected  into  the  field  of  operation,  thus  preventing  the  harmful 
afferent  impulses  arising  in  the  traumatized  area  from  reaching  the 
brain. 

Complications  during  anesthesia  arise  chiefly  from  interference 
with  the  respiratory  or  circulatory  apparatus,  the  former  more  par- 
ticularly with  ether  and  nitrous  oxid,  the  latter  with  chloroform.  A 
second  anesthesia,  within  a  few  hours,  is  always  more  dangerous  than 
the  first;  and  irregular  administration,  i.e.,  allowing  the  patient 
nearly  to  recover  and  then  forcing  the  anesthetic,  is  attended  by 
much  more  risk  than  a  uniformly  deep  narcosis. 

Respiratory  difficulties  may  be  due  to  many  causes  not  directly 
connected  with  the  anesthetic,  such  as  faulty  posture  of  the  patient, 
assistants  leaning  on  the  chest,  tight  bandages  about  the  neck  or 
chest,  swelhngs  within  or  about  the  air  passages,  excessive  distention 
of  the  abdomen,  and  diseases  of  the  lungs.  Any  of  these  should,  of 
course,  be  promptly  removed  if  possible.  It  may  be  said  at  once 
that  great  rapidity  or  cessation  of  the  respirations,  associated  with 
cyanosis  and  rapid  pulse,  calls  for  vigorous  measures.  If  the  cause  is 
not  obvious,  the  mouth  should  be  opened,  the  tongue  drawn  forward, 
and  the  pharynx  cleared.  If  this  does  not  overcome  the  difficulty, 
oxygen  and  strychnin  should  be  administered,  artificial  respiration 
employed  and,  if  necessary,  tracheotomy  or  intubation  be  performed. 
Only  those  causes  more  or  less  directly  connected  with  anesthesia 
will  be  considered  at  this  time.  Forgetting  to  breathe,  or  holding  the 
breath,  may  be  encountered  in  the  early  stages,  and  is  met  by  with- 
drawing the  anesthetic  and  perhaps  dashing  a  httle  ether  on  the 
chest  or  abdomen.  Falling  backwards  of  the  tongue  over  the  epiglottis 
requires  the  turning  of  the  patient's  head  to  one  side,  and  pressure 
behind  the  angles  of  the  jaw,  so  as  to  hft  it  forward.  Rarely  will  the 
mouth-gag  and  tongue  forceps  be  necessary  for  this  purpose.  The 
best  tongue  forceps  is  a  double  tenaculum,  which  secures  a  firm  hold 
without  crushing  or  bruising.  The  tongue  may  be  pressed  forward 
also  by  passing  a  finger  into  the  pharynx,  a  procedure  which  at  the 
same  time  will  reveal  any  other  form  of  obstruction.  Falling 
together  of  the  lips,  especially  in  toothless  patients,  with  or  without 
nasal  obstruction,  may  interfere  with  respiration.  All  that  need  be 
done  is  to  place  the  finger  or  the  end  of  a  towel  between  the  lips. 
Mucus,  saliva,  blood,  pus,  vomitus,  or  other  liquids  may  be  removed 
from  the  pharynx  by  turning  the  head  to  one  side,  and  swabbing  with 
gauze  sponges  secured  by  a  hemostat.  Spasm  of  the  respiratory 
muscles  requires  the  same  treatmet  as  falling  backwards  of  the 
tongue.     If  there  is  great  rigidity  of  the  muscles  of  the  jaw,  trache- 


ANESTHESIA 


33 


otomy  may  be  necessary.  Paralytic  arrest  of  respiration  may  be  pre- 
cipitated with  great  suddenness,  especially  with  chloroform.  With 
ether  the  approach  is  more  gradual;  the  respirations  become  weaker 
and  weaker,  the  pupils  dilate  and  remain  immobile,  the  color  grows 
tlusky  and  the  pulse  feeble.  The  treatment  is  artificial  respiration, 
the  administration  of  strychnin  subcutaneously,  and  inhalations  of 
oxygen.  Henderson  advises  that  the  oxygen  contain  lo  per  cent,  of 
COo.  He  belives,  since  CO2  is  the  predominant  stimulant  maintain- 
ing respiration,  that  apnea  is  not  infrequently  due  to  acapnia  (de- 
ficiency of  CO2),  the  result  of  excessive  breathing  during  the  stage 
of  excitement;  hence  unskilled  timidity  in  the  administration  ot  an 
anesthetic,  rather  than  overboldness,  may  be  responsible  for  some 
cases  of  respiratory  failure.  Edema  of  the  lungs  is  not  often  encoun- 
tered. The  patient  may  be  inverted  to  favor  drainage  from  the 
lungs,    and   oxygen   and    cardiac   stimulants   administered.     Vene- 


FiG.    7. —  Expiration.  Fig.   8. — Insi)iration. 

Figs.   7  and  8. — Artificial  Respiration.      (Esfnarch  and  Kowalzig.) 

section  is  sometimes  employed  to  relieve  the  right  side  of  the  heart, 
and  artificial  respiration  should  be  performed  if  breathing  ceases. 
Cyanosis  is  simply  a  symptom  which  has  foi  its  cause  one  of  the 
conditions  mentioned  above.  Artificial  respiration  is  best  done  by 
the  Sylvester  method.  One  should  first  make  sure  that  the  aii  pas- 
sages are  clear,  and  draw  out  the  tongue  to  establish  free  air  way. 
The  operator  stands  at  the  patient's  head,  grasps  the  arms  at  the 
elbows,  presses  them  firmly  against  the  sides  of  the  chest  to  induce 
expiration  (Fig.  7),  then  drav/s  the  arms  upward  until  they  almost 
meet  above  the  head,  in  order  to  raise  the  ribs  by  means  of  the  pec- 
toral muscles  and  thus  cause  inspiration  (Fig.  8).  These  movements 
should  be  repeated  about  fifteen  times  a  minute.  In  Mcr shall  Hall's 
method  the  operator  grasps  the  lower  thorax  with  his  hands,  presses 
upwards  and  inwards  for  two  01  three  seconds,  then  relaxes  the 
compression  for  two  or  three  seconds.     This  compression  can  be  made 


34  MANUAL  OF  SURGERY 

with  more  force  if,  as  in  the  Howard  method,  the  operator  kneels 
astride  the  patient's  hips,  braces  his  elbows  against  his  sides,  and 
throws  his  weight  upon  the  patient's  chest.  In  Schdfer's  method  the 
patient  lies  on  the  abdomen,  and  pressure  is  made  as  in  the  Howard 
method.  Laborde^s  method  consists  in  alternately  drawing  upon  and 
relaxing  the  tongue  at  intervals  of  four  seconds.  Feirs  method 
consists  in  the  introduction  of  a  tube  into  the  larynx,  or  through  a 
tracheotomy  wound,  respiration  being  maintained  by  means  of 
ioot-bellows.  When  the  bellows  are  connected  with  a  laryngeal 
tube  the  apparatus  is  known  by  the  name  of  Fell-0'Dwyer.  When 
ether  is  given  by  intratracheal  insufflation  artificial  respiration  may  be 
inaugurated  at  a  moment's  notice  by  insufflating  pure  air. 

Circulatory  Difficulties.- — A  mild  degree  of  syncope  sometimes 
results  from  nausea  and  vomiting.  Cardiac  failure  may  result  from 
operative  manipulations  during  light  narcosis,  overdose  of  the  anes- 
thetic, hemorrhage,  shock,  or  from  arrest  of  respiration.  Among  the 
measures  which,  after  withdrawing  the  anesthetic,  may  be  adopted 
in  cardiac  failure,  are  the  subcutaneous  administration  of  strychnin, 
atropin,  digitalis,  or  nitroglycerin,  inversion  of  the  patient,  artificial 
respiration,  faradism  of  the  phrenic  nerve  (one  pole  on  the  epigas- 
trium, the  other  at  the  junction  of  the  external  border  of  thesterno- 
mastoid  with  the  clavicle),  rubbing  the  extremities  toward  the 
heart,  compression  of  the  abdominal  aorta,  stretching  of  the  sphincter 
ani,  rhythmic  pressure  over  the  precordium,  and  direct  massage  of 
the  heart. 

Coughing  and  swallowing  during  the  induction  of  anesthesia 
indicate  that  the  vapor  is  too  strong.  Coughing,  swallowing,  or 
vomiting  during  the  third  stage  indicate  returning  consciousness 
and  call  for  more  anesthetic.  Vomiting  is  often  heralded  by  swallow- 
ing, shallow  breathing,  pallor,  feeble  pulse,  and  dilated  pupils,  a 
group  of  symptoms  which  may  be  confused  with  shock;  in  the 
latter  the  anesthetic  should  be  withdrawn,  in  the  former  it  should  be 
increased  in  order  to  prevent  the  vomiting.  If  vomiting  occurs,  the 
head  should  be  turned  to  one  side  and  the  stomach  contents  allowed 
to  escape,  swabbing  out  the  pharynx  if  necessary.  Hiccough  is  most 
apt  to  occur  during  abdominal  operations  and  usually  demands  an 
increase  of  the  anesthetic. 

Recovery  from  anesthesia  varies  in  duration  according  to  the  char- 
acter and  quantity  of  the  anesthetic  and  the  condition  of  the  patient. 
After  nitrous  oxid  and  ethyl  chlorid  it  occurs  immediately  on  with- 
drawal of  the  anesthetic,  usually  without  any  special  phenomena. 
After  ether  and  chloroform  the  temperature  is  usually  subnormal,  the 


ANESTHESIA  35 

respirations  arc  (juict,  the  eyeballs  rotate,  the  lid  reflex  returns, 
swallowing  begins,  and  vomiting  often  follows.  Some  patients 
remain  quiet,  many  become  noisy  and  turbulent.  'I'he  anesthetist  or 
a  competent  nurse  should  remain  with  the  patient  until  recovery  is 
complete.  The  head  should  be  low  and  turned  to  one  side,  and  the 
patient  kept  warm.  Vomited  matter  should  be  received  in  a  towel  or 
basin  without  raising  the  head.  Food  is  rarely  given  before  six 
hours,  and  often  not  for  many  hours.  Vomiting  is  more  frequent 
after  ether,  but  is  apt  to  be  more  severe  and  protracted  after  chloro- 
form.    As  a  rule  it  ceases  of  itself  and  no  treatment  is  required. 

After  effects  more  frequently  follow  ether  than  other  anesthetic 
agents.  In  order  to  minimize  the  unpleasant  sequelae  of  inhalation 
anesthetics,  one  may  inject,  during  or  immediately  after  operation, 
saline  solution  into  the  subcutaneous  tissues,  or  i  or  2  quarts  of 
water,  containing  i  or  2  ounces  of  glucose,  into  the  rectum.  The 
fluid  restores  the  blood  pressure,  and  dilutes  and  assists  in  the  elimina- 
tion of  the  anesthetic.  The  glucose  reestablishes  the  glycogenic 
function  of  the  liver.  Gastric  lavage,  at  the  completion  of  operation, 
assists  in  eliminating  the  anesthetic,  and  tends  to  prevent  nausea 
and  vomiting. 

Conjunctivitis,  and  burns  of  the  first  degree  about  the  face  and 
neck  may  occur,  particularly  if  ether  or  chloroform  has  been  "poured 
on. "  Persistent  vomiting  may  be  due  to  acute  gastrectasia,  peritonitis, 
intestinal  obstruction,  opium,  or  other  causes  independent  of  the 
anesthetic,  and  these  should  be  excluded  before  deciding  that  the 
anesthetic  is  wholly  responsible.  Acetonuria,  which  is  described 
below,  may  be  the  cause  or  the  effect  of  protracted  vomiting.  Con- 
tinued vomiting  due  to  the  anesthetic  alone  is  best  treated  by 
withholding  all  food  by  mouth,  gastric  lavage,  nutritive  enemata 
containing  sodium  bromid,  and,  to  hasten  elimination  of  the  anes- 
thetic, fresh  air  and  hypodermoclysis.  Later  champagne  and 
various  liquid  foods  may  be  tried.  Bronchial  and  pulmonary  affec- 
tions are  often  due  to  the  irritation  of  ether,  but  may  arise  also  from 
exposure  of  the  patient,  the  inhalation  of  septic  material,  emboli, 
interference  with  respiration  (e.g.,  from  an  epigastric  incision),  and 
sluggish  circulation  (e.g.,  from  a  weak  heart  or  prolonged  recum- 
bency). Ether  pneumonia  is  of  the  lobular  variety  and  quickly 
follows  anesthesia.  Pneumonia  from  other  causes  may  be  of  the 
lobar  variety  and  may  not  arise  for  a  number  of  days.  Preventive 
measures  consist  in  the  use  of  a  clean  inhaler,  the  exclusion  of  foreign 
material  from  the  air  passages,  and  the  careful  protection  of  the 
patient.     (See  also  "Pulmonary  Embolism.")     Bronchial  irritation, 


36  MANUAL  OF  SURGERY 

and  possibly  bronchitis,  may  be  caused,  as  already  pointed  out, 
by  the  decomposition  of  chloroform  in  the  presence  of  a  naked  flame. 
Renal  complications  may  occur  after  ether,  chloroform,  or  ethyl 
chlorid.  Whether  they  are  more  frequent  after  ether  than  after 
chloroform  does  not  seem  to  be  satisfactorily  settled.  The  urine  is 
always  decreased  in  quantity  during  the  first  twenty-four  hours  after 
anesthesia,  and  should  be  carefully  watched.  If  signs  of  renal  in- 
competency appear,  heat  should  be  applied  over  the  kidneys,  diu- 
retics administered,  and  water  given  by  mouth,  rectum,  subcutane- 
ously,  or  intravenously.  Apoplexy  may  occur  in  those  with  chronic 
arterial  disease,  but  is  rare  if  the  patient  is  skillfully  and  thoroughly 
anesthetized;  the  struggling  induced  by  pushing  the  anesthetic  or 
by  operating  before  anesthesia  is  complete  is  dangerous  in  these 
cases.  Complete  anesthesia  is  usually  less  to  be  feared  than  fright 
and  pain.  Insantiy  has  followed  anesthesia  in  those  so  predisposed. 
Post-anesthetic  paralysis  may  result  from  cerebral  hemorrhage 
or  embolism,  but  is  usually  the  result  of  pressure,  e.g..  a  wrist  drop 
due  to  the  hanging  of  an  arm  over  the  edge  of  a  table.  This  subject, 
with  the  position  to  be  assumed  by  the  upper  extremities,  is  referred 
to  in  the  chapter  on  "Surgical  Technic."  Acetonuria  (acetonemia, 
acid  intoxication)  rarely  follows  the  administration  of  any  anesthetic 
except  chloroform,  in  which  event  it  is  called  delayed  chloroform 
poisoning.  That  chloroform  occasionally  produces  glycosuria  has 
long  been  known,  but  only  recently  has  attention  been  directed  to  the 
form  of  late  poisoning  described  below.  It  is  more  apt  to  occur  in 
children,  and  after  quickly  repeated  anesthesias.  Other  predisposing 
causes  are  diabetes,  disease  of  the  liver  or  kidneys,  exhaustion,  and 
infection.  The  condition  may  appear  in  from  a  few  hours  to  many 
days  after  the  anesthesia,  and  it  may  last  several  days  and  end  in 
recovery,  or  progress  and  terminate  in  death.  The  symptoms  are 
vomiting,  rapid  pulse,  dyspnea,  cyanosis,  delirium  or  stupor,  and 
finally  coma.  The  breath  has  a  sweetish,  chloroform-like  odor,  and 
there  may  be  fever.  The  urine  contains  acetone  and  diacetic  acid, 
and  sometimes  leucin  and  tyrosin.  Jaundice  may  occur  and  there 
may  be  a  tendency  to  hemorrhage.  Autopsy  reveals  fatty  degenera- 
tion of  the  liver  and  sometimes  of  the  kidneys  and  other  organs,  the 
changes  being  much  like  those  found  in  phosphorus  poisoning.  The 
treatment,  at  least  so  far  as  the  acetonemia  is  concerned,  consists  in 
the  use  of  measures  to  promote  elimination,  stimulation  if  necessary, 
glucose  or  levulose  by  lectum,  and  the  administration  of  bicarbonate 
of  soda  by  mouth,  or  i  per  cent,  in  salt  solution  by  rectum,  sabcu- 
taneously,  or  intravenously. 


ANESTHESIA  37 

Local  Anesthesia  is  llu-  production  of  insensibility  in  the  parts  to 
be  operated  upon,  without  destroying  the  general  bodily  sensibility 
or  producing  unconsciousness.  It  is  indicated  in  minor  operations, 
and  in  major  surgery  when  general  anesthesia  is  contraindicated. 
It  is  nat  satisfactory  in  children,  in  nervous  patients,  or  in  cases 
in  which  muscular  relaxation  is  desired.  Local  anesthesia  may  be 
induced  by  freezing,  or  by  the  application  or  injection  of  various 
drugs. 

Freezing  may  be  produced  by  spraying  the  parts  with  ether, 
rhigolene,  chlorid  of  methyl,  liquid  air,  or  chlorid  of  ethyl.  Chlorid 
of  ethyl  is  the  agent  usually  employed.  It  is  put  up  in  glass  tubes,  and 
is  sprayed  on  the  part  from  a  distance  of  about  one  foot.  When  the 
part  becomes  hard  and  white  it  is  ready  for  incision.  The  anesthesia 
lasts  from  one  to  two  minutes.  Both  the  freezing  and  the  thawing 
are  painful.  In  the  absence  of  ethyl  chlorid  freezing  may  be  induced 
by  ice  and  salt,  in  the  proportion  of  two  parts  of  the  former  to  one  of 
the  latter,  placed  in  a  gauze  bag  and  appHed  to  the  skin;  analgesia 
results  in  about  fifteen  minutes. 

Cocain  hydrcchlorid  is  an  efficient  local  anesthetic,  but  is  not 
without  danger.  Death  has  resulted  from  one  dram  of  a  20  per  cent, 
solution  instilled  into  the  urethra,  and  from  swabbing  the  larynx  with 
a  2  per  cent,  solution.  Not  more  than  one-half  a  grain  should  be 
used  for  injection,  not  over  two-thirds  of  a  grain  should  be  appUed 
to  a  mucous  membrane.  Cocain  poisoning  is  characterized  by 
headache,  nausea  and  vomiting,  pallor,  tremor,  restlessness,  dryness 
of  the  mouth,  dilatation  of  the  pupils,  weak  pulse,  prolonged  in- 
somnia, and  in  severe  cases  by  delirium,  unconsciousness,  and  heart 
failure.  The  treatment  consists  in  placing  the  patient  recumbent, 
applying  external  heat,  and  administering  cardiac  stimulants.  Co- 
cain is  contraindicated  in  glaucoma  because  it  dilates  the  pupils; 
it  is  said  also  to  have  a  deleterious  effect  upon  diseased  kidneys. 
As  cocain  is  destroyed  by  prolonged  boiling,  the  solution  is  best 
prepared  (fresh  each  time)  by  adding  to  normal  salt  solution  the 
crystals  which  have  been  sterilized  in  glass  tubes  at  300°F.,  dry 
heat,  for  fifteen  or  twenty  minutes.  The  strength  of  the  solution 
should  be  from  2  to  4  per  cent,  for  the  eye,  4  per  cent,  for  the  urethra, 
2  per  cent,  for  the  bladder,  5  to  10  per  cent,  for  the  rectum,  vagina, 
mouth,  nostrils,  and  from  i^?  to  i  per  cent,  for  injection  into  any 
portion  of  the  body. 

Eucain  hydrochlorid  (beta-eucain)  is,  for  practical  purposes,  just 
as  powerful  as  cocain,  one-quarter  as  toxic,  and  is  not  destroyed  by 
boiling.     Solutions  for  injection  should  be  from  i  to  4  per  cent.     It 


38 


MANUAL  OF  SURGERY 


does  not  cause  dilatation  of  the  pupil,  nor  is  it  followed  by  as  marked 
congestion  as  cocain.  Sloughing  has,  however,  been  observed  in  a 
few  instances  after  its  use. 

Stovain,  novocain,  and  tropacocain  are  closely  related  to  cocain, 
but  the  first  is  four  times  and  the  other  two  seven  times  less  toxic 
than  it  and  all  are  just  as  anesthetic.  They  come  already  sterilized 
in  closed  tubes.  For  injection  a  3^:^  to  i  per  cent,  solution  in  sterile 
water  or  salt  solution  may  be  employed.  For  infiltration  125  cc.  of  a 
}4  to  \  2  per  cent,  novocain  solution  can  be  used  with  safety. 

Procain  is  the  official  name  of  the  American  made  novocain. 
Clinically  its  action  is  the  same  as  that  of  novocain. 

Adrenalin  chlorid,  when  added  to  any  of  the  drugs  mentioned 
causes  exsanguination  of  the  part  by  constricting  the  blood 
vessels,  thus  lessening  the  hemorrhage,  limiting  absorption,  and 
intensifying    and    prolonging    the    anesthesia.     Barker   prepares    a 

solution  by  adding  to  100  cc.  of 
boiled  distilled  water  i  cc.  of 
adrenalin  chlorid  (i  to  i.ooo),  3 
grains  of  eucain,  and  12  grains  of 
sodium  chlorid.  Not  more  than 
fifteen  drops  of  adrenalin  chlorid 
should  be  added  to  any  solution 
for  injection. 

Quinin-urea  hydrochlorid,  in- 
jected in  from  J^  to  i  per  cent,  in  salt 
solution,  induces  prolonged  anes- 
thesia, hence  lessens  post-operative  pain.  It  is  not  toxic  and  dimin- 
ishes bleeding.  Induration  and  tardy  healing  sometimes  follow  its  use. 
Schleich's  solution  produces  anesthesia  by  causing  an  artificial 
edema,  the  tension  resulting  in  ischemia  and  in  pressure  on  the  nerve 
endings,  hence  the  term  infiltration  anesthesia  (Fig.  9).  Sterile 
water  or  normal  salt  solution  produces  much  the  same  effects,  but 
is  not  quite  as  efficient.  Schleich  uses  three  solutions  as  follows: 
No.  I  (for  the  most  painful  operations — not  more  than  5  drams 
should  be  used)  consists  of  cocain  hydrochlorid  gr.  iii,  morphin 
hydrochlorid  gr.  3^,  sodium  chlorid  gr.  iii,  distilled  water  f§iiiss, 
acid  carbolic  (5  per  cent.)  gtt.  iii.  Solution  No.  2  (of  which  not  more 
than  10  drams  should  be  injected)  is  used  in  less  painful  operations, 
and  is  the  same  as  No,  i  except  that  the  cocain  is  reduced  to  gr.  iss. 
Solution  No.  3  (used  in  deeper  and  less  sensitive  tissues  and  in  ex- 
tensive operations — 11  oz.  may  be  injected)  contains  but  gr.  }q  of 
cocain.     Adrenalin  chlorid  also  may  be  added  to  these  solutions. 


Fig.  9. — Method  of  injecting  local 
anesthetics  into  the  skin.  The  fluid  is  in- 
troduced into  and  not  beneath  the  skin, 
which  is  elevated,  tense,  and  white. 


ANESTHESIA  39 

The  injection  of  local  anesthetics  may  be  by  the  direct  method,  i.e., 
the  (iriig  is  injected  into  the  tissues  to  be  operated  upon,  or  by  the 
indirect  method  {regional  anesthesia),  in  which  the  drug  is  injected 
into  (intraneural)  or  about  (paraneural)  the  nerve  or  nerves  supplying 
the  part  with  sensation,  into  the  blood  vessels  of  the  part  (Bier, 
Ransohojf).  or  into  the  subarachnoid  space  of  the  spinal  cord  (spinal 
anesthesia).  In  the  direct  method,  whenever  possible,  e.g.,  in  the 
fingers,,  toes,  and  penis,  a  tight  ligature  should  be  placed  above 
the  area  to  be  anesthetized,  after  it  has  been  exsanguinated  by  eleva- 
tion, or  in  some  cases,  by  pressure;  this  in  itself  has  a  benumbing 
influence,  as  well  as  restricting  the  anesthetic  solution  to  the  in- 
jected area.  After  making  sure  that  all  air  has  been  driven  from  the 
syringe  (a  hypodermic,  antitoxin,  or  special  syringe  may  be  em- 
ployed), the  point  of  the  needle  is  inserted  obliquely  into  the  skin 
until  the  eye  is  just  beneath  the  epidermis;  in  other  words,  an  effort 
is  made  to  enter  the  true  skin  and  not  the  subcutaneous  tissues. 
Care  should  be  taken  not  to  enter  a  vein.  A  few  drops  of  the  solution 
are  introduced,  producing  a  white  wheal;  the  needle  is  then  pushed 
a  little  farther,  and  the  process  repeated  until  the  proposed  line  of 
incision  is  marked  out  by  a  white  and  elevated  ridge  (Fig.  9).  From 
five  to  ten  minutes  should  elapse  before  making  the  incision.  If  the 
deeper  structures  are  to  be  severed,  they  also  should  be  infiltrated, 
or  one  of  the  more  powerful  solutions  may  be  dropped  in  the  wound. 
Intra-  or  paraneural  injections  may  be  employed  in  amputation 
of  the  finger,  by  forcing  the  solution  into  the  tissues  about  its  base, 
when  the  entire  finger  will  become  anesthetic.  In  amputation  of  the 
leg  the  tissues  over  the  sciatic  and  long  saphenous  nerves  may  be 
infiltrated  with  Schleich  solution,  and  the  nerves  exposed  and  in- 
jected with  a  1 2  to  I  per  cent,  cocain  solution.  In  amputations  of 
the  thigh  it  wall  be  necessary  to  inject  the  anterior  crural  instead  of 
the  long  saphenous  nerve.  Many  other  operations  may  be  performed 
by  this  method.  In  paravertebral  and  parasacral  anesthesia  the 
spinal  nerves  are  injected  at  the  points  where  they  emerge  from  the 
bony  foramina.  Most  of  the  structures  of  the  body  are  without  pain 
sensation.  The  skin,  the  subcutaneous  tissues,  and  the  periosteum 
are  the  most  sensitive  parts.  Once  the  parietes  have  been  severed 
the  brain  may  be  cut  without  an  anesthetic,  and  the  lungs,  heart, 
liver,  kidneys,  spleen,  stomach,  and  intestines  may  be  incised  and 
sutured  without  sensation,  provided  traction  or  pressure  is  not  made 
on  their  parietal  connections. 

In  Bier's  intravenous  anesthesia,  after  rendering  the  limb 
bloodless  with  an  Esmarch  bandage,  a  tourniquet  is  placed  above  and 


40  MANUAL  OF  SURGERY 

another  below  the  field  of  operation.  Under  infiltration  anesthesia 
a  cannula  is  inserted  into  a  superficial  vein  immediately  below  the 
proximal  tourniquet,  and  from  40  to  100  cc.  of  novocain  (.5  per  cent, 
in  salt  solution),  at  the  temperature  of  the  body,  injected  towards 
the  periphery.  Anesthesia  is  induced  between  the  tourniquets  in 
from  2  to  5  minutes;  beyond  the  distal  tourniquet  in  from  5  to  15 
minutes,  when  the  distal  tourniquet  may  be  removed.  At  the 
completion  of  the  operation  the  proximal  band  is  removed  gradually, 
to  prevent  rapid  diffusion  of  the  novocain.  Ransohojf  applies  an 
Esmarch  band  to  the  limb  with  sufficient  firmness  to  obstruct  the 
venous  flow,  and  under  infiltration  anesthesia  injects,  with  a  fine 
needle,  4  to  8  cc.  of  a  .5  per  cent,  cocain  solution  into  the  main 
artery.  Anesthesia  results  in  2  minutes,  after  which  the  band  may 
be  tightened  to  check  oozing.  These  methods  are  still  in  the  ex- 
perimental stage  and  must  be  used  with  caution.  They  are  con- 
traindicated  in  the  presence  of  vascular  disease. 

Spinal  anesthesia,  or  medullary  narcosis,  is  produced  by  the 
injection  of  a  local  anesthetic  into  the  subarachnoid  space.  Cocain 
and  eucain  are  seldom  used  at  the  present  time.  Stovain  has  a 
strong  afhnity  for  the  motor  nerves  and  may,  in  high  anesthesia, 
cause  paralysis  of  the  respiratory  muscles.  Tropacocain  and  novo- 
cain possess  less  of  this  affinity,  hence  are  safer;  the  usual  dose  is 
from  one-half  to  one  grain.  The  solution  is  prepared  by  dissolving 
the  drug  selected  (previously  sterilized)  in  cerebrospinal  fluid,  which 
is  drawn  into  the  syringe  containing  the  anesthetic,  after  the  intro- 
duction of  the  needle  into  the  subarachnoid  space.  In  order  to  make 
the  solution  of  a  higher  specific  gravity  than  the  spinal  fluid  and  so 
remain  in  the  lower  part  of  the  spinal  theca,  Barker  uses  distilled 
water  i  cc,  glucose  .05  grams,  and  stovain  .1  gram.  The  syringe 
should  be  boiled  in  plain  water,  as  the  soda  solution  employed  for 
other  instruments  may  diminish  the  efficacy  of  the  anesthetic.  The 
patient  hes  on  the  side  or  assumes  the  sitting  posture;  in  either  case 
the  back  should  be  bent  forward  in  order  to  increase  the  space 
between  the  vertebral  arches.  The  operator  places  one  finger  upon 
the  spine  of  the  fourth  lumbar  vertebra,  which  is  on  a  line  drawn 
between  the  two  ihac  crests,  and  enters  the  needle,  fitted  with  a 
stylet,  just  below  and  to  the  right  of  this  point,  in  a  slightly  upward 
and  inward  direction,  until  the  dura  has  been  punctured,  which  in 
the  adult  is  usually  at  a  depth  of  two  and  one-half  inches.  The 
stylet  is  withdrawn  and  one  dram  of  the  cerebrospinal  fluid  allowed 
to  escape.  The  anesthetic  solution  is  then  slowly  injected,  the  needle 
withdrawn,  and  the  puncture  sealed  with  collodion.     The  patient  is 


ANESTHESIA  4 1 

placed  in  the  proper  position  for  operation,  but  never  should  the 
head  and  shoulders  be  on  a  lower  level  than  the  lumbar  vertebrae,  as 
the  fluid  may  gravitate  towards  the  medulla  and  cause  respiratory 
paralysis.  Anesthesia  results  in  about  five  minutes  and  lasts  from 
one  to  three  hours  or  longer.  No  attempt  should  be  made  to  induce 
anesthesia  above  the  diaphragm.  Headache,  nausea,  and  vomiting  are 
frequent  sequelae,  and  evidence  of  transient  and  permanent  cord 
injuries  has  been  noted.  The  chief  dangers  are  infection,  injury  to 
the  cord,  and  poisoning  from  the  anesthetic  employed.  The  mor- 
tality has  been  estimated  at  i  in  200.  From  what  has  been  said  it 
may  be  gathered  that  the  method  is  destined  to  pass  into  desuetude. 


CHAPTER  HI 
INFECTION  AND  DISINFECTION 

-For  a  full  discussion  of  the  various  phases  in  the  vital  circle  of 
micro-organisms  and  the  different  theories  of  immunity  the  student  is 
referred  to  a  text-book  on  bacteriology.  The  few  facts  here  sum- 
marized are  intended  merely  as  an  outline  to  recall,  from  a  surgical 
standpoint,  the  important  features  of  these  subjects. 

Bacteria,  schizomycetes,  or  fission  fungi,  are  microscopic,  non- 
nucleated,  unicellular,  vegetable  organisms,  devoid  of  chlorophyl  and 
consisting  of  protoplasm  inclosed  in  a  cell  wall.  The  terms  germ, 
microbe,  and  micro  organism  also  are  loosely  applied  to  bacteria  and 
allied  organisms. 

According  to  shape  (Fig.  io)  bacteria  are  divided  into  cocci  (spheri- 
cal), hacilli  (rod-like  or  cyhndrical),  and  spirilla  (spiral).  Cocci  (mi- 
crococci) are  divided  according  to  number  into  monococci  (existing 
singly),  diplococci  (in  pairs),  tetracocci  (groups  of  four),  and  sarcincB 
(cubical  groups  of  eight) ;  according  to  arrangement  into  streptococci 
fchain-like)  and  staphylococci  (irregular  masses  like  bunches  of 
grapes).  Globular  masses  held  together  by  gelatinous  matter  are 
called  zooglea;  a  group  of  cocci  in  a  capsule,  ascococci.  BacilU  in 
chain  formation  are  called  streptohacilli. 

The  distribution  of  bacteria  is  almost  universal.  They  exist  in  the 
air.  water,  food,  soil,  ahmentary  canal  (being  most  numerous  in  the 
mouth,  lower  ileum,  and  cecum),  nose,  lower  urethra,  and  vagina, 
and  even  in  the  hair  follicles  and  sweat  glands  of  the  skin. 

The  reproduction  of  bacteria  takes  place  by  fission,  i.e.,  the  cell 
simply  divides  into  two  or  more  fragments  when  it  has  reached  the 
stage  of  maturation.  When  subjected  to  conditions  inimical  to 
growth  a  few  bacilli  (e.g.,  B.  anthracis,  tetani,  and  edematis  mahgni) 
and  spirilla  undergo  sporulation.  This  is  generally  regarded  as  a 
resting  stage,  or  "as  a  method  of  encystment  for  the  purpose  of 
resisting  unfavorable  environment"  (Hiss  and  Zinsser).  A  spore  is 
analogous  to  the  seed  of  a  plant,  and  may  appear  in  the  end  of  the 
organism  (ends pore),  or  in  the  middle  (endospore),  thus  making  the 
organism  club-shaped  or  fusiform.  Although  as  a  rule  only  one 
spore  forms,  a  number  may  develop  throughout  the  length  of  the 
organism,    presenting    a   bead-like    appearance    {arthros pores).     A 

42 


IN'FEC  TIOX  AXD  DISIN'FECTIOX 


43 


spore  has  a  dense  capsule  which  renders  it  very  resistant  to  all  kinds 
of  disinfectants. 

For  development  bacteria  require  a  temperature  at  or  near  that 
of  the  human  body,  moisture,  and  food.  Their  food  consists  of 
complex  organic  compounds,  such  as  are  found  in  the  bodies  of 
animals  and  in  plants.  Parasites  grow  in  living  tissues,  saprophytes, 
or  putrefactive  organisms,  in  dead  tissues.     Like  the  cells  of  the 


Sarcinx  (packet  cocci). 


^ 


Cocci. 


Staphylococci. 


Diplococci. 


Sfreptococcd.  -^., 


-\J    \     «* 


Teliacocci. 


f  Ciliated  cell.   _\ 


Flagellate 
Bacilli. 


r  Diplococcus.  -— ^..__  J 


(    Spider  cell. 


sules 

i  Monococcus 

Centrally  situated  spores. 

Clostridia  forms 
Knobbed  bacteria  wi 
terminal  spores 


t. 
£y  y 


rms.  ___L_-«0 


/ 


0,yvft/w 


Zooglea. 


Slender  bacilli. 

Short  badlli. 

Bacilli  in  chains  (st re ptotacilli). 

Vibrio  (spirillum). 

Comma  bacilli. 
Spirochaeta. 


Fig.    10. — Diagram   illustrating  the   nomenclature   of  schizomycetes  based  upon  their 
morphology.     (Coplin  after  Shenk.)       X  about  700  diameters. 


human  body,  bacteria  attract  elements  essential  for  their  growth 
(positive  chemotaxis)  and  repel  those  which  ar  harmful  (negative 
chemotaxis) .  Aerobic  bacteria  require  oxygen  for  their  development; 
anaerobic,  e.g.,  the  bacillus  of  tetanus,  of  malignant  edema,  of 
botulism,  and  the  bacillus  aerogenes  capsulatus,  the  absence  of 
oxygen.  An  obligate  aerobe  is  obhged  to  have  oxygen  in  order  to 
Hve.  An  obligate  anaerobe  cannot  live  with  oxygen.  A  facultative 
aerobe  is  an  anaerobe  that  has  the  facultv  of  livinor  with  oxvgen. 


44  "      MANUAL  OF  SURGERY 

Most  pathogenic  micro-organisms  diVe  facultative  anaerobes,  i.e.,  they 
thrive  best  with  oxygen,  but  have  the  faculty  of  Hving  without  it. 
The  terms  facultative  and  obligate  are  applied  also  to  parasites  and 
saprophytes.  Motile  bacteria  possess  the  power  of  moving  from 
place  to  place  by  means  of  thread-like  processes,  or  flagellce  (e.g.,  B. 
typhosus  and  B.  coh),  or  by  means  of  a  rotary  or  undulatory  motion; 
amotile  bacteria  (all  cocci  and  most  bacilli)  depend  for  transportation 
upon  fomites  or  upon  physical  or  chemical  currents.  In  common  with 
other  minute  particles  suspended  in  fluid,  bacteria  oscillate  {Brownian 
movements) . 

Bacterial  death  occurs  when  the  developmental  conditions 
mentioned  above  are  absent  or  unfavorable.  It  is  caused  also  by 
disinfection,  by  the  cells  and  fluids  of  the  human  body,  and  by  the 
organisms  themselves;  thus,  like  animals,  they  may  succumb  to  the 
poisons  generated  by  their  own  activities.  In  the  tongue,  liver, 
brain,  female  breast  and  pelvis,  and  elsewhere  the  surgeon  sometimes 
finds  the  destructive  effects  of  bacteria  that  have  perished  with  the 
lapse  of  time. 

Freezing  renders  bacteria  inert,  but  does  not  destroy  them.  Dry- 
ing renders  them  dormant,  but  permits  of  their  dissemination  by 
means  of  the  air.  However,  desiccation  is  ultimately  fatal  to  most 
bacteria;  the  gonococcus  survives  complete  deprivation  of  moisture 
only  a  few  hours.  It  is  important  to  remember  that  bacteria  are 
not  blown  or  driven  from  moist  surfaces,  and  that  a  table,  for  in- 
stance, which  is  wiped  with  a  damp  cloth  is  not  as  dangerous  from  a 
surgical  standpoint  as  one  which  is  dusted.  Direct  sunlight,  the 
X-rays,  radium,  electric  currents,  and  electric  light,  are  detrimental 
to  the  growth  of  microbes. 

Bacterial  products  represent  the  excretions  of  bacteria,  the  sub-  , 
stances  generated  by  their  decomposition,  and  the  compounds 
resulting  from  the  action  of  either  of  these  on  the  tissues.  Bacteria 
may  produce  alcohols;  acids,  such  as  lactic,  acetic,  and  butyric; 
alkahes,  e.g.,  ammonia;  and  pigments  (c/?rowogc«ic  bacteria),  e.g., 
bacillus  pyocyaneous;  some  are  capable  of  causing  phosphorescence 
{photogenic).  The  aerogenic  (gas  producing)  bacteria  are  the  bacillus 
aerogenes  capsulatus,  the  bacillus  of  malignant  edema,  the  bacillus 
coh,  and  many  other  saprophytes  (see  "Gas  Gangrene")-  Zymo- 
genic bacteria  cause  fermentation. 

The  ferments,  or  enzymes,  Hke  the  digestive  juices,  emulsify  fats, 
change  albumin  into  peptone  and  starch  into  sugar.  The  enzymes 
may  be  absorbed  in  the  human  body  and  produce  disease.  The 
other  poisonous  substances  elaborated  by  bacteria  are  the  ptomains, 


INFECTION  AND  DISINFECTION  45 

the  toxalbumins,  and  the  toxins.  A  ptomain  is  a  crystallizable 
alkaloid  produced  by  the  action  of  bacteria  on  dead  animal  matter. 
Toxalbumins  are  amorphous  albumoses  ])roduced  by  the  action  of 
enzymes  on  albumin.  Toxins  are  crystallizable  alkaloids  existing  in 
the  protoplasm  of  bacteria  and  excreted  by  them  (cctoloxin),  as  in 
diphtheria  and  tetanus,  or  liberated  by  their  death  {endotoxin),  as  in 
tuberculosis.  The  term  toxin  as  commonly  employed  means  any 
or  all  of  the  poisonous  substances  elaborated  by  bacteria,  and 
the  condition  resulting  from  the  absorption  of  these  toxins  is  called 
toxemia. 

Pathogenic  bacteria  arc  those  which  produce  disease.  They  are 
usually  parasites,  but  many  saprophytes  may  acquire  parasitic 
tendencies,  and  even  an  obligate  saprophyte  may,  when  acting  on 
dead  tissue  in  the  human  body,  cause  general  symptoms  of  intoxica- 
tion; hence  a  sharp  line  cannot  be  drawn  between  parasites  and  sapro- 
phytes, although  the  latter  are  ordinarily  nonpathogenic,  i.e.,  incapable 
of  producing  disease,  and  many  of  these  are  not  only  harmless, 
but  even  useful,  producing  alcoholic  and  acetous  fermentation,  and 
cleansing  the  earth  of  dead  animal  and  vegetable  matter  by  putre- 
faction. To  demonstrate  that  a  micro-organism  is  the  specific 
cause  of  a  given  disease,  it  should  fulfil  KocJis  postulates,  which  are, 
that  it  be  found  in  every  case  of  that  disease,  that  it  be  absent  in 
normal  tissues  under  normal  conditions,  that  it  be  cultivated  in  pure 
culture,  that  these  cultures  be  capable  of  reproducing  the  disease, 
and  that  the  germ  be  again  cultivated  in  pure  culture  from  the  in- 
fected animal.  To  these  has  been  added  the  isolation,  from  the 
cultures  of  the  organism,  of  a  toxin  which  will  produce  the  disease  or 
elaborate  an  antitoxin  in  susceptible  animals. 

Contamination,  or  potential  infection,  should  be  clearly  separated 
from  actual  infection.  A  contaminated  wound  harbors  bacteria  in  a 
state  of  incubation,  and  it  is  in  this  period  of  incubation,  which  varies 
in  length  from  a  few  hours  to  many  days,  according  to  the  invading 
organism,  that  active  prophylactic  measures  may  avert  disease. 

Infection  means  that  pathogenic  bacteria  have  entered  the  living 
tissues  of  the  body  and  caused  disea,se.  A  wound  may  be  infected 
with  only  one  variety  of  bacteria  {pure  infection) ,  or  with  more  than 
one  variety  {mixed  infection) ;  and  a  primary  infection  may  be  fol- 
lowed by  a  reinfection  with  the  same  organism,  or  by  a  secondary 
infection  with  another  organism,  thus  explaining  the  care  with  which 
a  surgeon  sterilizes  his  hands  and  instruments,  even  when  the  tissues 
are  known  to  be  infected.  When  bacteria  become  encapsulated  with 
fibrous  tissue,  or  remain  quiescent  for  other  reasons,  the  condition  is 


46  MANUAL  OF  SURGERY 

called  latent  infection.  It  is  of  great  significance,  not  only  in  elucidat- 
ing pathogenesis,  but  also  in  operative  surgery,  e.g.,  an  operation  on  a 
limb  previously  infected  and  healed  may  give  rise  to  the  same  infec- 
tion, the  bacteria  being  mobilized  by  the  trauma  of  the  operation; 
in  other  cases  a  different  infection  becomes  active,  thus  tetanus  has 
followed  the  extraction  of  a  bullet  months  after  the  original  wound 
had  healed.  Autoinfection  is  illustrated  by  miliary  tuberculosis 
originating  in  a  tuberculous  lymph  gland.  Suhinfection  is  a  slight, 
chronic,  or  repeated  infection,  perhaps  symptomless,  which  may 
result  in  immunity.  In  mixed  infection  one  form  of  bacteria  may 
antagonize  another  form  {antibiosis,  enantiobiosis) ,  or  the  varieties 
may  harmonize  in  their  development  (symbiosis) . 

The  usual  methods  of  infection  are  through  wounds  (inoculation), 
through  the  mucous  membrane  of  the  ahmentary  canal  (ingestion), 
through  the  mucous  membrane  of  the  respiratory  passages  (inhala- 
tion). Bacteria  rarely  pass  through  intact  healthy  skin.  It  is 
known  that  micro-organisms  may  pass  through  the  placenta.  Germi- 
nal infection  (infected  ovum  or  spermatozoon)  is  very  doubtful, 
although  it  has  been  held  responsible  for  some  of  the  cases  of  con- 
genital syphilis. 

Infection  extends  by  continuity,  as  when  it  creeps  along  a  surface 
or  plane  of  tissue;  or  by  contiguity,  as  when  it  spreads  from  one 
organ  or  tissue  to  another,  e.g.,  from  the  ovary  to  the  appendix. 
Transportation  from  one  part  of  the  body  to  another  is  effected  by 
the  blood  or  the  lymph,  the  bacteria  floating  free  in  the  stream,  or 
being  carried  by  cells  or  emboli,  by  secretions,  excretions  (e.g.,  from 
the  kidney  to  the  bladder  by  the  urine) ,  or  pathologic  discharges,  e.g., 
from  the  lung  to  the  intestine  by  swallowed  sputum.  Transmission 
outside  of  the  body  also  may  occur,  e.g.,  when  gonococci  are  con- 
veyed from  the  urethra  to  the  eyes  by  the  fingers. 

Disease  production  is  not  the  direct  result  of  the  deposition  of 
bacteria,  that  is,  the  process  is  not  a  mechanical  one.  They  may 
injure  the  tissue  cells  by  stealing  their  food,  but  as  a  rule  the  morbid 
phenomena  are  due  to  toxins,  which  act  locally,  generally,  or  both. 
The  local  changes  are  usually  of  a  defensive  (inflammatory)  or 
destructive  nature  (suppuration,  ulceration,  gangrene),  but  may, 
as  in  tetanus,  be  entirely  absent.  The  general  changes  in  pyogenic 
infections  are  those  of  fever  (see  "  Sepsis"),  but  in  some  other  surgical 
infections,  e.g.,  tetanus  and  hydrophobia,  the  temperature,  at  least 
in  the  early  stages,  is  normal.  The  behavior  of  infection,  as  will  be 
indicated  on  later  pages,  may  be  influenced  mechanically,  e.g.,  by 
the  site  of  inoculation  and  the  structure  of  the  invaded  parts,  and 


INFECTION  AND  DISINFECTION  47 

chemically,  e.g.,  by  the  reciprocal  affinity  existing  between  various 
toxins  and  tissues. 

The  determining  factors  in  the  production  of  infection  are  the 
dose  of  the  micro-organisms,  their  virulence,  and  the  resistance  of  the 
tissues.  Many  of  the  organisms  entering  the  tissues  are  swallowed 
by  the  leukocytes  or  dissolved  by  the  bactericidal  action  of  the  blood 
serum,  so  that  probably  a  large  number  are  necessary  for  the  produc- 
tion of  morbid  phenomena.  The  virulence  of  micro-organisms 
depends  chiejfly  on  their  environment,  thus  when  passed  through  a 
series  of  animals  they  become  acclimated  and  more  dangerous  for 
that  species,  and  when  subjected  to  unfavorable  circumstances 
(improper  amount  of  heat,  water,  food,  air)  they  become  less  harm- 
ful. The  resistance  of  the  tisues  varies  from  extreme  susceptibility 
to  absolute  immunity. 

Increased  susceptibility  may  be  due  to  local  and  general  causes. 
The  local  causes  are  (i)  ischemia  from  scars,  pressure  (including 
tight  stitches  and  bandages),  and  diseases  and  injuries  of  vessels;  (2) 
diseases  and  injuries  of  nerves;  (3)  obstruction  of  a  duct,  which 
prevents  the  escape  of  any  bacteria  that  may  be  present,  permits 
decomposition  of  the  retained  secretion  or  excretion,  and  produces 
increased  tension,  consequently  ischemia,  of  the  duct  and  reservoir 
(e.g.,  gall  bladder,  urinary  bladder)  above  the  obstruction;  (4) 
destruction  of  cells  as  the  result  of  mechanical,  chemical,  or  thermal 
injury;  (5)  peculiarities  of  the  individual  tissues,  depending  upon 
structure,  function,  and  situation.  The  general  causes  are  referable 
mainly  to  the  blood,  to  the  tissue  cells,  and  to  nervous  influences. 
The  blood  suffers  deterioration  in  anemia,  underfeeding,  overcrowd- 
ing, and  in  intoxications,  e.g.,  from  diabetes,  nephritis,  and  other 
diseases,  from  drugs,  including  alcohol  and  prolonged  anesthesia, 
and  perhaps  from  fatigue.  One  infection,  e.g.,  syphilis,  tuberculosis, 
may  by  altering  the  composition  of  the  blood  predispose  to  other 
infections.  The  tissue  cells,  among  which  should  be  included  the 
leukocytes,  when  surprised  by  an  infection  with  which  they  are  not 
accustomed  to  deal,  may  succumb  to  the  toxins  through  lack  of 
experience  in  preparing  specific  antibodies.  The  composition  of  the 
blood  and  tissue  cells  and  the  amount  of  training  they  have  had  in 
manufacturing  specific  antibodies  may  explain  why  susceptibility  or, 
inversely,  insusceptibility  to  a  particular  microbe  varies  in  dift'erent 
individuals,  and  according  to  age,  sex,  race,  and  species. 

Insusceptibility,  or  immunity,  to  an  infection  may  be  natural  or 
acquired.  Natural  immunity  is  illustrated  in  the  negro,  who  possesses 
an  inherent  resistance  to  yellow  fever.     Acquired  immunity  may  be 


48  MANUAL  OF  SURGERY 

active  or  passive.  Active  immunity,  so  called  because  the  tissue  cells 
are  activated  to  form  antibodies,  is  produced  by  a  previous  attack  of 
a  disease,  e.g.,  syphilis  and  the  exanthemata;  by  direct  inoculation, 
such  as  was  o/ice  employed  in  small-pox,  and  is  still  used  for  certain 
diseases  in  animals;  by  the  introduction  of  attenuated  virus,  e.g., 
vaccination  for  small-pox  and  the  prophylactic  treatment  of  hydro- 
phobia; and  by  the  injection  of  bacterins.  Passive  immunity  is 
produced  by  the  injection  of  immune  serum  (vide  infra),  and  in- 
volves no  action  on  the  part  of  the  tissue  cells. 

Theories  of  Immunity .^ — The  body  defends  itself  against  infection 
(i)  by  destroying  bacteria  and  (2)  by  neutralizing  their  toxins. 

(i)  The  antibacterial  methods  of  defense  are  (a)  phagocytosis 
and  (b)  bacteriolysis,  (a)  Phagocytosis  is  the  process  whereby 
microbes  are  devoured  and  digested  by  certain  cells  of  the  body, 
especially  the  leukocytes;  these  cells  are  called  phagocytes.  Leukocy- 
tosis, local  or  general,  or  both,  is  nature's  effort  to  supply  a  sufhcient 
number  of  phagocytes  to  overcome  the  invading  bacteria,  and  the 
surgeon  sometimes  tries  to  assist  nature  in  this  effort,  e.g.,  by  apply- 
ing heat,  inducing  passive  hyperemia  (Bier),  or  by  injecting  nucleinic 
acid  (Mikulicz)  or  horse  serum  (Petie).  The  substances  in  the  blood 
serum  which  prepare  bacteria  for  phagocytosis  are  termed  opsonins. 

(b)  Bacteriolysis  is  the  dissolving  of  bacteria,  in  the  blood  serum 
and  body  fluids,  by  an  albuminous  substance  (bacteriolysin)  furnished 
chiefly  by  the  leukocytes.  Buchner  believes  there  is  but  one  bac- 
teriolysin,  which  he  calls  alexin,  for  all  bacteria  and  that  it  exists  in 
normal  serum;  others,  that  there  is  a  separate  antibody  manufactured 
for  each  bacterium.  The  serum  of  animals  immunized  to  the  bacilli 
of  typhoid  fever,  cholera,  and  the  bacillus  coli,  cause  agglutination, 
or  clumping,  of  the  respective  microbes.  The  Widal  test  for  typhoid 
fever  is  based  on  this  phenomenon.  This  clumping  is  probably  a 
preliminary  step  to  bacteriolysis,  but  some  attribute  it  to  specific 
bodies,  called  agglutinins  or  precipitins. 

(2)  The  antitoxic  method  of  defense  consists  in  the  formation  of 
antitoxins  by  the  blood  and  tissue  cells  as  the  result  of  the  action  of 
bacterial  antigens.  An  antigen  is  any  substance  (bacterial  toxins, 
alien  blood  serum  and  cells,  certain  animal  poisons,  etc.)  which 
causes  the  generation  of  antibodies  (lysins,  agglutinins,  antitoxins, 
opsonins) .     Antitoxins  neutralize  toxins  but  have  no  effect  on  bacteria. 

Ehrlich  explains  the  phenomena  of  immunity  by  the  side-chain 
theory.  He  believes  that  every  living  cell  consists  of  a  central  body, 
and  of  a  number  of  other  chemical  groups  or  side-chains  (receptors) 
which  are  especially  concerned  with  nutrition.     A  toxin  consists  of 


INFECTION  AND  DISINFECTION  49 

two  chemical  groups,  the  toxic  carrying  portion  (loxophorc)  and  a 
combining  portion  [haplopliorc) .  When  a  toxin  enters  the  circulation, 
it  must  find  receptors  to  lit  its  haptophore  group,  in  order  to  exert 
a  deleterious  action  on  the  cells.  The  toxophore  group  without  its 
haptophore  group,  and  a  toxin  whose  haptophore  group  cannot  find 
an  affinity  for  receptors,  are  harmless.  When  a  toxin  combines 
with  a  cell,  the  receptors  are  destroyed,  and  the  cell  makes  an  effort 
to  supply  the  loss,  producing  many  more  receptors  than  are  neces- 
sary; these  are  thrown  into  the  circulation  and  constitute  antitoxin, 
because  when  they  meet  with  the  toxin,  they  immediately  combine 
with  its  haptophore  group  and  render  it  inert.  Certain  of  these 
receptors,  called  also  immune  bodies  and  amboceptors,  have  two 
combining  groups,  one  (cytophile)  for  bacteria  or  other  cells,  the 
other  (complementophile)  for  the  complement.  The  complement 
(bacteriolysin,  alexin)  dissolves  bacteria  after  being  fixed  to  them  by 
the  amboceptor. 

In  accordance  with  the  theories  outlined  above,  infections  may 
be  prevented  or  combated  by  means  of  (i)  immune  serums,  (2) 
attenuated  forms  of  virus,  and  (3)  bacterins. 

(i)  Immime  serums,  when  injected  into  the  body,  produce  passive 
immunity  They  are  obtained  from  specially  immunized  animals, 
and  are  (a)  antitoxic  or  (b)  antibacterial,  (a)  Antitoxic  serums  are 
laden  with  antitoxin,  produced  by  the  injection  of  toxins  into  an 
animal;  such  are  the  antitoxins  of  pneumonia,  plague,  hydrophobia, 
diptheria,  tetanus,  staphylococci  and  streptococcic  infections,  and 
antivenine;  the  last  is  non-bacterial,  (b)  Antibacterial  serums  con- 
tain bacteriolysins  and  amboceptors,  hence  kill  bacteria;  such  are 
he  typhoid,  dysentery,  anthrax,  and  cholera  serums.  Those  serums 
which  are  of  interest  to  the  surgeon  receive  notice  under  the  diseases 
for  which  they  are  used. 

Serum  disease  is  the  name  given  to  certain  symptoms  which 
occasionally  follow  serotherapy,  sometimes  immediately,  but  more 
often  after  an  interval  of  from  eight  to  twelve  days.  The  most 
frequent  of  these  symptoms  are  pain  and  swelling  at  the  site  of  in- 
jection, pain  and  swelling  of  the  adjacent  lymph  glands,  pains  in  the 
joints,  fever,  general  urticaria  or  erythema,  slight  albuminuria,  and 
leucopenia.  Great  weakness,  dyspnea,  cough,  edema  of  the  face, 
and  swelling  of  the  tongue  may,  however,  occur,  and  a  few  cases  of 
sudden  death  have  been  reported.  Asthmatics  are  especially  prone 
to  suffer  from  disagreeable  or  dangerous  sequelce.  The  nature  of 
serum  disease  is  not  thoroughly  understood,  but  when  it  follows  a 
second  injection  of  serum,  it  is  supposed  to  be  due  to  supersensitive- 


50  MANUAL  OF  SURGERY 

ness.  Super  sensitiveness^  or  anaphylaxis,  in  contradistinction  to 
prophylaxis,  is  the  increased  susceptibility  to  serum  (or  to  any 
proteid)  arising  in  an  animal  as  the  result  of  a  sub-toxic  dose  pre- 
viously administered,  the  theory  being  that  the  tissue  cells  have  been 
educated  by  the  first  injection  to  split  up  the  proteid,  hence  when  a 
second  injection  is  given  the  process  takes  place  so  rapidly  that  the 
animal  is  overwhelmed  by  the  toxic  portion  of  the  proteid. 

(2)  An  attenuated  virus  is  employed  in  the  prophylactic  treat- 
ment of  hydrophobia  (q.v.),  and  small-pox  is  prevented  by  vaccina- 
tion with  an  attenuated  form  of  small-pox  (cow-pox). 

(3)  A  bacterin,  or  vaccin,  is  a  suspension  of  dead  bacteria  with 
their  toxins  in  salt  solution.  Tuberculin,  which  must  be  put  in  this 
class,  contains,  however,  only  toxins  and  is  made  up  with  glycerin 
or  water.  Here  should  be  mentioned  also  Coley's  fluid  which  on  em- 
pirical grounds  is  used  in  the  treatment  of  malignant  growths  (see 
"Sarcoma"").  Bacterins  are  injected  into  the  body  with  the  idea  of 
inducing  active  immunity,  especially  by  increasing  the  opsonic  index 
and  thus  stimulating  phagocytosis.  The  opsanioindex  is  the  amount  of 
opsonin  in  the  patient's  serum  compared  with  that  in  normal  serum. 
It  is  determined  by  dividing  the  number  of  bacter'a  ingested  by 
the  leukocytes  of  the  patient's  blood,  by  the  number  ingested  by 
those  of  healthy  blood,  100  or  more  leukocytes  being  searched;  thus 
if  400  are  found  in  the  leukocytes  of  normal  blood  and  300  in  those 
of  the  patient's  blood,  the  opsonic  index  is  .75.  The  hope  that  the 
opsonic  index  might  be  a  value  in  diagnosis  and  prognosis  seems  far 
from  realization,  and  as  a  guide  to  the  dose  of  bacterins  it  is  seldom 
employed.  Bacterins  shouM.  whenever  possible,  be  autogenous,  i.e., 
made  by  taking  the  organisms  directly  from  the  individual  to  be 
treated.  When  this  is  not  done  one  may  employ  a  stock  bacterin.  i.e. , 
one  already  prepared  from  the  organisms  obtained  from  another  indi- 
vidual suffering  from  the  same  infection .  The  stock  bacterins  supplied 
by  manufacturing  chemists  have  the  number  of  bacteria  in  each  cc, 
usually  40  to  600  millions,  marked  on  the  tubes.  The  initial  dose 
varies  according  to  the  infection.  5  to  25  miUions  being  the  average. 
This  is  followed  by  a  fall  (negative  phase),  then,  in  a  few  days,  by  a 
rise  in  the  opsonic  index  (positive  phase).  The  injections  are  gener- 
ally given  at  intervals  of  from  5  to  10  days,  and  never  when  the  nega- 
tive phase  manifests  itself  clinically  by  aggravation  of  the  symptoms. 
In  prophylaxis,  typhoid  vaccin  has  proved  of  great  value,  but  in  the 
treatment  of  disease  vaccins  have  been  a  disappointment.  They  are 
contraindicated  in  acute  spreading  infections  accompanied  by  toxemia. 

Other  pathogenic  micro-organisms  besides  bacteria  are: 


INFECTION  AND  DISINFECTION  5 1 

1.  Hypomyceles,  or  mold,  fungi  which  consist  of  fihiments,  or 
hyphie,  often  forming  an  interlacing  network,  called  the  mycelium; 
these  fungi  multi})ly  by  sporulation.  Thrush  iroidium  albicans), 
favus  (achorion  Schonleinii),  and  certain  other  skin  diseases  are 
caused  by  molds.  The  streptothricoses  (actinomycosis  and  myce- 
toma) should  lie  mentioned  here,  although  the  organisms  belonging 
to  the  streptothrix  group  are  said  to  occupy  a  position  some  where 
between  the  molds  and  bacteria. 

2.  The  yeasts,  hlastomyceles,  or  saccharomyceles,  which  multii)ly 
by  budding,  or  gemmation,  cause  bread  to  rise,  and  are  responsible 
for  many  forms  of  fermentation.  Blastomycetic  dermatitis  is  due 
to  yeast  fungi,  and  some  suppose  that  a  yeast  causes  cancer. 
Sporotricosis  is  closely  allied  to  blastomycosis. 

3.  Protozoa,  which  are  microscopic  unicellular  organisms  belong- 
ing to  the  lowest  form  of  animal  lite.  Malaria  (plasmodium  ma- 
lariae),  trypanosomiasis  (sleeping  sickness),  syphilis  (spirocheta) , 
and  certain  forms  of  dysentery  (ameba  coli)  are  due  to  protozoa, 
and  carcinoma,  variola,  and  molluscum  contagiosum  are  supposed 
to  be  due  to  protozoa. 

Special  surgical  micro-organisms  are  mentioned  under  the  diseases 
for  which  they  are  responsible. 

Disinfection,  or  sterilization,  is  the  destruction  of  germs  outside 
or  on  the  surface  of  the  body.  The  agent  by  which  disinfection  is 
effected  is  called  a  disinfectant,  or  germicide.  An  antiseptic  restricts 
or  prevents  the  development  of  micro-organisms;  as  commonly 
employed,  however,  the  term  is  synonymous  with  germicide  and 
disinfectant.  A  deodorizer,  e.g.,  charcoal,  may  destroy  an  offensive 
odor,  but  is  not  necessarily  an  antiseptic.  Asepsis  means  the 
absence  of  bacteria;  antisepsis  includes  all  the  measures  taken  for 
the  destruction  of  bacteria.  Disinfection  may  be  divided  into  (i) 
mechanical,  (2)  thermal,  or  (3)  chemical. 

1.  Mechanical  disinfection  is  the  mordant  for  other  forms  of 
disinfection;  it  consists  in  shaving,  scrubbing  with,  soap  and  water, 
and  irrigation.  Without  it  many  chemical  disinfections  are  useless, 
with  it  even  the  mildest  are  highly  efficient. 

2.  Thermal  disinfection,  or  heat,  is  the  most  effectual  of  all 
forms  of  sterilization,  and  should  be  used  whenever  possible.  Moist 
heat  (boihng  water  or  other  liquids,  and  steam)  is  more  efficient  than 
dry  heat.  Steam  may  be  quiescent  (simple  steam),  live  steam,  or 
steam  under  pressure.  Live  steam  is  better  than  simple  steam,  and 
steam  under  pressure  is  the  best  of  all.  An  autoclave  (Fig.  11)  is  a 
sterilizer  into  which  steam  is  introduced   under  high  pressure.     A 


52 


MANUAL  OF  SURGERY 


vacuum  is  first  created,  thus  allowing  greater  penetration  of  the 
steam  into  the  articles  within  the  chamber.  The  steam  is  under  a 
pressure  of  from  lo  to  15  pounds  to  the  square  inch  at  24o°F.  At 
the  completion  of  the  process  of  sterilization  a  vacuum  is  again 
created  and  the  objects  dried.  By  means  of  this  apparatus  complete 
sterilization  (10  pounds  pressure  at  240°F.)  of  ordinary  dressings, 
etc.,  takes  place  in  three-fourths  of  an  hour.  Material  for  steriliza- 
tion in  the  autoclave  should  be  loosely  packed,  should  not  come  in 
contact  with  the  walls  of  the  sterilizer,  and  should  be  heated  before 
the  steam  is  turned  on.  Simpler  and  cheaper  sterilizers,  without 
the  advantage  of  pressure,  also  are  on  the  market.  Dry  heat  (flame, 
hot  air,  actual  cautery,  etc.)  is  rarely  employed. 

3.  Chemical  disinfection  is  of  less  value  than  the  mechanical  and 
the  thermal  methods.  The  principal  conditions  governing  the 
germicidal  action  of  a  chemical  are  its  strength 
and  the  medium  in  which  the  bacteria  exist.  A 
chemical  sufficiently  strong  to  be  rapidly  germi- 
cidal will  kill  not  only  bacteria,  but  also  the 
tissue  cells.  If  the  medium  containing  the 
bacteria  is  distilled  water  an  added  germicide 
comes  at  once  in  contact  with  the  organisms 
and  acts  promptly;  whereas  serum,  pus,  and 
other  exudates  protect  the  bacteria  mechan- 
ically, and  weaken  the  disinfectant  by  combin- 
ing with  it.  The  time  the  chemical  remains  in 
contact  with  the  microbes  also  has  some  in- 
fluence, and,  generally  speaking,  the  hotter  and 
fresher  the  solution  the  greater  its  power  as  a 
disinfectant,  a'lthough  heat  may  cause  congestion  and  excessive  heat 
may  devitalize  the  tissue  cells.  In  using  germicides  one  should 
always  keep  in  mind  the  possibility  of  poisoning,  both  local  and 
general.  Of  the  many  chemical  disinfectants  the  most  important 
are  mentioned  below. 

Bichlorid  of  mercury  {corrosive  sublimate)  is  a  white  poisonous 
powder,  used  as  a  solution  in  water.  As  the  solution  is  colorless  and 
odorless  a  small  quantity  of  eosin  should  be  added,  so  that  it  may  readily 
be  distinguished  from  other  fluids.  Bichlorid  of  mercury  is  very  fastid- 
ious in  its  action;  thus  it  decomposes  when  brought  in  contact  with 
metallic  apparatus,  and  is  inert  in  the  presence  of  alkalies  and  al- 
bumins, so  that  solutions  must  be  made  with  distilled  or  filtered 
water.  The  union  of  bichlorid  of  mercury  with  albumin  may  be 
prevented  by  the  addition  of  tartaric  or  citric  acid,  which,  it  should  be 


Fig.   II. — Autoclave. 


INFECTION  AND  DISINFECTION  53 

remembered,  will  have  the  same  effect  also  on  albumins  which  may 
be  administered  to  combat  poisoning.  Bichlorid  solutions  should 
be  fresh,  as  standing  for  some  time  impairs  their  power,  owing  to  the 
formation  of  an  oxychlorid;  this  may  be  prevented  by  the  addition  of 
ammonium  chlorid  or  sodium  chlorid.  For  convenience  bichlorid 
is  put  up  in  tablets  containing  7.3  grains  of  corrosive  sublimate 
and  an  equal  amount  of  ammonium  chlorid;  one  of  these 
tablets  added  to  a  pint  of  water  makes  a  i  to  1000  solution.  It  is 
never  used  in  clean  wounds,  as  it  destroys  some  of  the  cells  and  causes 
exudation;  and  because  of  its  irritating  qualities,  it  is  never  applied 
to  serous  membranes,  such  as  the  peritoneum,  meninges,  pleura  and 
synovial  membranes.  For  the  skin  it  is  employed  in  the  strength  of 
I  to  1000;  for  wounds,  i  to  2000;  for  the  vagina,  i  to  5000;  for  the 
urethra,  i  to  10,000;  and  for  the  conjunctivae,  i  to  40,000.  Unless 
one  is  accustomed  to  its  use  corrosive  sublimate  frequently  causes  a 
cracking  and  blackening  of  the  hands.  Occasionally  bichlorid  of 
mercary  causes  a  severe  dermatitis  with  the  formation  of  pustules, 
and  it  is  sometimes  absorbed  from  wounds,  producing  constitutional 
symptoms  of  poisoning,  viz.,  salivation,  stomatitis,  metallic  taste  in 
the  mouth,  foul  breath,  vomiting,  colicky  pains  in  the  abdomen, 
diarrhea,  nephritis,  and  in  very  severe  cases  collapse  and  death;  the 
drug  is  withdrawn,  of  course,  on  the  first  indication  of  absorption. 
Carbolic  acid,  or  phenol,  occurs  as  crystals  which  deliquesce  on 
exposure  to  air,  the  resulting  fluid  being  called  pure  carbolic  acid.  It 
is  rarely  used  in  wounds  because  of  its  irritating  effects,  although  it 
penetrates  fatty  tissues.  It  is  a  good  deodorizer,  however,  and  is  often 
put  into  ointments  because  of  its  feeble  anesthetic  properties.  It  is 
not  used  on  the  hands,  because  it  roughens  and  cracks  them  and 
impairs  their  sensibility.  When  powerful  solutions  are  applied  for  a 
long  time,  gangrene  may  result.  It  finds  its  chief  office  in  the  disin- 
fection of  materials  which  do  not  stand  boiling  well.  Pure  carbolic 
acid  is  occasionally  employed  to  sterilize  badly  infected  wounds, 
alcohol  being  used  one  or  two  minutes  later  for  the  purpose  of 
neutralization.  When  the  weaker  solutions  (i  to  5  per  cent.)  are 
continuously  applied  to  a  wound,  absorption  and  poisoning  may 
ensue;  the  pure  acid  produces  a  superficial  area  of  coagulation  which 
prevents  its  absorption.  One  of  the  first  symptoms  of  absorption 
is  smoky,  greenish,  or  blackish  urine  (carboluria) .  Later  there  may 
be  vomiting,  headache,  vertigo,  sweating,  feeble  pulse,  irregular  and 
rapid  breathing,  great  weakness,  and  subnormal  temperature.  The 
treatment  consists  in  withdrawal  of  the  drug,  stimulation,  and  sodium 
sulphate  or  Epsom  salts. 


54  MANUAL  OF  SURGERY 

Lysol  and  creolin  are  coal-tar  derivatives,  which  are  feebler  than 
carbolic  acid,  but  less  toxic  and  irritating.  Each  may  be  used  in  the 
strength  of  3  per  cent. 

Hydrogen  peroxid  is  frequently  employed  to  cleanse  suppurating 
areas.  It  is  a  fluid  which,  when  applied  to  a  wound,  sets  free  from 
ten  to  fifteen  times  its  volume  of  oxygen,  producing  ebullition,  and 
probably  destroying  the  elements  upon  which  bacteria  live.  It 
should  be  kept  in  a  dark  and  cold  place,  should  ordinarily  be  used  in 
half  strength,  and  should  never  be  injected  into  deep  sinuses  unless 
a  large  external  opening  exists,  as  the  liberated  gas  may  do  great 
harm  by  pressure.  In  order  to  render  hydrogen  peroxid  less  irritat- 
ing, the  acid  which  the  manufacturers  put  into  the  fluid  to  preserve 
it  may  be  neutralized  by  adding  a  small  quantity  of  sodium  bicar- 
bonate, but  only  when  the  peroxid  is  to  be  used  at  once,  since  the 
alkali  hastens  its  decomposition. 

Permanganate  of  potassium  is  a  good  deodorizer  for  foul  wounds, 
sloughing  tumors,  etc.,  in  the  strength  of  from  ^  10  to  5  per  cent.  It 
is  used  for  disinfecting  the  hands  (saturated  solution  in  water)  and 
as  an  antidote  to  snake  poisoning. 

Alcohol  is  employed  chiefly  for  the  preservation  of  surgical  mate- 
rials, such  as  sutures,  etc.,  for  the  disinfection  of  instruments  with 
keen  edges,  for  the  disinfection  of  the  hands  previous  to  operation 
(see  "Surgical  Technic"),  and  to  remove  fatty  material  from  the  skin 
previous  to  the  application  of  bichlorid  of  mercury.  Gasoline, 
ether,  henzin,  and  turpentine  also  are  occasionally  useful  for  the  last 
purpose.     All  of  these  are  inflammable. 

Formaldehyd  is  a  powerful  antiseptic  gas,  which  is  sold  as  a  40 
per  cent,  solution  in  water,  under  the  name  of  formalin.  It  is  very 
irritating,  and  should  rarely  be  applied  to  living  tissues ;  some  opera- 
tors employ  a  2  per  cent,  solution  for  the  disinfection  of  instruments. 
Glutol,  or  formalin  gelatin,  is  a  powder  which  gives  off  formalin  when 
brought  in  contact  with  wound  secretions. 

Boric  acid  (saturated  solution  in  water)  is  a  mild  antiseptic, 
which  is  indicated  when  more  powerful  but  more  irritating  disin- 
fectants cannot  be  employed. 

Tincture  of  iodin  is  now  being  widely  employed  for  disinfection 
of  the  skin  previous  to  operation,  as  described  in  the  chapter  on 
"Surgical  Technic."  It  is  strongly  recommended  also  for  the  steril- 
ization of  infected  wounds.  It  may  be  apphed,  full  strength,  at  long 
intervals,  or  the  wound  may  be  irrigated  daily  with  a  i  per  cent,  solu- 
tion. In  irrigating  large  wounds  with  iodin  solution,  the  possibility 
of  poisoning  should  be  kept  in  mind. 


INFECTIOX  AND  DISINFFXTION  55 

Iodoform  is  a  yellow  powder  with  a  disagreeable  smell.  It 
liberates  iodia  when  brought  in  contact  with  wound  secretions,  and 
so  creates  an  unfavorable  held  for  bacteria;  but  bacteria  may  grow 
upon  dry  iodoform,  so  that  it  must  be  sterilized  for  at  least  five 
minutes  by  washing  in  a  i  to  10,000  bichlorid  of  mercury  solution. 
It  is  frequently  used  as  iodoform  gauze,  or  as  an  emulsion  in  ether, 
glycerin,  vaselin,  or  sweet  oil.  Its  chief  value  is  supposed  to  be  in 
tuberculosis,  owing  to  its  ability  to  produce  fibrous  tissue  as  the  result 
of  the  irritating  action  of  the  iodin.  Iodoform  sometimes  causes  a 
severe  dermatitis,  and  occasionally  constitutional  symptoms  of  poison- 
ing. In  some  cases  there  is  marked  gastrointestinal  irritation,  such 
as  vomiting  and  diarrhea;  in  others  cerebral  symptoms,  such  as  de- 
lirium or  melancholia;  in  either  case  there  is  fever,  yellowness  of  the 
conjunctivae,  suffusion  of  the  eyes  with  contraction  of  the  pupils^  a 
metallic  taste  in  the  mouth,  an  odor  of  iodoform  upon  the  breath, 
and  iodin  in  the  saliva  and  urine.  A  rash  upon  the  skin,  rapid  ema- 
ciation, and  nephritis  are  not  infrequent.  Many  substitutes  have 
been  proposed  for  iodoform,  but  nothing  as  efficient  for  tuberculous 
lesions  has  yet  been  created.  The  odor  of  iodoform  may  be  made 
less  disagreeable  by  the  addition  of  one  of  the  aromatic  oils.  Except 
in  tuberculosis  the  author  never  uses  iodoform  and  rarely  any  other 
antiseptic  powder.  Powders,  as  ordinarily  used  from  a  box  which  is 
exposed  to  the  air  and  dust,  are  laden  with  germs ;  hence  are  contrain- 
dicated  in  aseptic  wounds,  and  much  better  means  of  disinfection  may 
be  found  for  infected  wounds.  A  cetanilid  when  freely  used  is  positi\'ely 
dangerous;  cyanosis  and  collapse  may  follow,  especially  in  the  old, 
the  young,  or  the  debilitated.  Smaller  doses,  frequently  appHed,  as 
iii  the  dressing  of  ulcers,  may  lead  to  chronic  poisoning  (anemia, 
mental  hebetude,  and  congestion  of  the  liver,  spleen,  and  kidneys). 

The  salts  of  silver,  e.g.,  silver  nitrate,  lactate  (actol),  citrate 
(itrol),  coUargol,  protargol,  and  argyrol  have  antiseptic  properties. 
All  but  the  first  are  proprietary  preparations.  The  indications  tor 
these  salts  will  be  given  in  subsequent  pages.  Silver  foil  is  occasion- 
ally applied  to  wounds. - 

Dyes  as  disinfectants  have  recently  attracted  notice.  Malachite 
green,  2  per  cent,  in  alcohol  (80  per  cent.)  mixed  with  an  equal 
volume  of  a  2  per  cent,  solution  of  mercuric  chlorid  in  alcohol  (80 
per  cent.)  is  recommended  by  Cheatle.  Hexamethyl  violet, 
and  brilliant  green  (the  last  in  the  strength  of  i  to  1000  in  water) 
also  are  said  to  have  pronounced  germicidal  properties.  Acri- 
flavine  and  proflavine  are,  according  to  Browning,  powerful  anti- 
septics, whose  action  is  increased  by  serum,  though  diminished  by 


56  MANUAL  OF  SURGERY 

pus.  They  are  less  detrimental  to  phagocytosis  than  other  disin 
fectants,  but  act  more  slowly,  and  are  generally  used  in  the  strength 
of  I  to  1000  in  normal  salt  solution.  Dakin  and  Dunham  believe 
that  the  germicidal  action  of  these  substances  has  been  overestimated. 
Of  the  chlorin  group  of  antiseptics  hypochlorous  acid,  Dakin's 
solution,  and  dichloramin  T.  are  the  rriost  important  members. 

Hypochlorous  acid  is  a  strong  germicide,  which,  in  the  strength 
of  .5  per  cent.,  produces  little  irritation  of  the  tissues  (Lorraine 
Smith).  Eupad  consists  of  equal  parts  of  chlorinated  lime  and 
boric  acid.  When  dusted  on  a  wound  it  liberates  hypochlorous  acid, 
hence  acts  at  a  distance,  but  should  be  applied  for  a  short  time  only. 
Eusol  is  made  by  adding  25  grams  of  eupad  to  one  litre  of  water. 
After  standing  for  a  few  hours  the  solution  is  filtered.  It  contains 
.54  per  cent,  of  hypochlorous  acid.  Eusol  has  been  extensively  em- 
ployed as  a  substitute  for  Dakin's  solution. 

Dakin's  solution  is  a  neutral,  or  slightly  alkahne,  solution  of 
sodium  hypochlorite  in  the  strength  of  from  .45  to  .50  per  cent.  It 
can  be  made  in  several  ways.  The  method  of  Dau<fresne,  which  is 
the  most  popular,  is  as  follows:  To  make  10  litres  of  solution  put 
184  grams  of  chlorinated  lime  (containing  25  per  cent,  active  chlorin) 
in  a  10  litre  bottle  with  5  litres  of  water.  Shake  well  and  let  stand  6 
or  more  hours.  Dissolve  92  grams  of  dry  sodium  carbonate  (or 
262  grams  of  the  crystalline  salt)  and  76  grams  of  sodium  bicarbonate 
in  5  litres  of  water,  add  this  solution  to  the  suspension  of  chlorinated 
lime,  shake  well,  and  allow  to  stand  for  one-half  hour  so  that  the 
calcium  carbonate  may  precipitate.  The  clear  fluid  is  then  siphoned 
off  and  filtered  through  paper. 

In  order  to  determine  the  quantity  of  active  chlorin  in  the  chlori- 
nated lime  the  following  test  must  be  made  every  time  a  new  product 
is  received.  Mix  20  grams  of  the  sample  in  a  litre  of  water,  and 
leave  in  contact  a  few  hours.  Measure  10  cc.  of  the  clear  fluid  and 
add  20  cc.  of  a  10  per  cent,  solution  of  potassium  iodid  and  2  cc.  of 
acetic  acid  or  hydrochloric  acid;  then  put,  drop  by  drop,  into  the 
mixture  a  decinormal  solution  of  sodium  hyposulphite  (2.48  per  cent.) 
until  decoloration.  The  number  of  cubic  centimeters  of  hyposulphite 
employed,  multiplied  by  1775  will  give  the  weight  (N)  of  active 
chlorin  contained  in  100  grams  of  chlorinated  lime.  When  the 
result  obtained  is  not  25  per  cent.,  the  proportions  of  the  three  in- 
gredients of  the  preparation  must  be  adjusted  accordingly.  This 
can  be  done  by  multiplying  each  of  three  figures  given  in  the  formula 

184,  92,  76)  by  25/N,  in  which  N  represents  the  active  chlorin  per- 

entage  in  the  sample  of  chlorinated  lime. 


INFECTION  AND  DISINFECTION  57 

To  estimate  the  hypochlorite  content  of  Dakin's  solution  measure 
lo  cc.  of  the  solution,  add  20  cc.  of  a  10  per  cent,  potassium  iodid 
solution,  then  2  cc.  of  acetic  or  hydrochloric  acid,  and  then  drop  by 
drop,  a  decinormal  solution  of  sodium  hyposlphite  until  decoloration. 
The  number  of  cubic  centimetres  used  multiplied  by  .03725  will 
give  the  weight  of  sodium  hypochlorite  in  100  cc.  of  the  solution. 

The  reaction  of  the  solution  is  determined  by  sprinkling  on  it  a 
few  grains  of  powdered  phenolphthalein.  The  correct  solution  shows 
no  discoloration,  while  Labarraque's  solution  and  Eau  de  Javel 
give  an  intense  red  color,  indicating  the  presence  of  free  caustic 
alkali. 

Dakin's  solution  should  be  freshly  prepared  each  day  and  accur- 
ately tested  by  titration  for  its  hypochlorite  content  and  neutral 
reaction.  It  should  be  stored  only  in  dark  amber  bottles  and  in  a 
cool  place.  The  fluid  when  brought  in  contact  with  a  wound  rapidly 
liberates  its  chlorin  in  from  3  to  7  minutes,  which  unites  with  the 
organic  matter  and  produces  new  substances  known  as  chloramins; 
that  which  combines  with  the  bacteria  acts  as  a  direct  germicide. 
These  chloramins,  though  more  stable  chemical  compounds  than  the 
hypochlorites,  also  liberate  chlorin  and  thus  continue  the  germicidal 
reactions  with  bacteria  until  the  chlorin  becomes  so  firmly  bound 
that  chemical  actions  ceases.  Unfortunately  the  mass  of  chlorin 
available  in  the  clinically  usuable  strength  of  the  hypochlorites,  0.45 
per  cent,  is  almost  negligible  as  a  germicide  and  thus  the  direct 
germicidal  effect  of  the  hypochlorites,  in  this  strength,  and  the  chlora- 
mins that  may  be  formed,  are  small  factors  in  the  clinical  results 
obtained  with  these  solutions.  Dakin  and  Dunham  believe  when 
the  chlorin  breaks  way  from  the  hypochlorite  radical  NaO-Cl  a 
hydrogen  atom  unites  with  the  remaining  NaO  to  form  NaOH  or 
caustic  soda.  It  is  the  solvent  or  proteolytic  effect  of  this  sodium 
hydroxide  upon  the  dead  and  devitalized  wound  contents,  and 
the  consequent  elimination  of  bacterial  food,  that  is  the  real  factor 
in  the  sterilization  of  wounds  with  this  solution;  an  indirect 
germicidal  action  similar  to  the  action  of  hydrogen  peroxid;  a 
chemical  debridement.  This  chemical  action  is  said  to  last  from 
30  minutes  to  i  hour,  hence  the  necessity  for  frequent  instillation  of 
the  solution  into  a  wound.  Dakin's  solution  dissolves  dead  tissue, 
including  catgut,  and  corrodes  metallic  instruments.  It  also  causes 
irritation  of  the  skin,  which  may  be  prevented  by  applying  vaselin. 
The  Carrel  technic  for  the  treatment  ot  wounds  with  Dakin's  fluid  is 
described  in  the  chapter  on  "Wounds."  The  disadvantages  of  the 
Carrel-Dakin  metliod  of  wound  treatment  are  the  skin  irritation, 


58  MANUAL  OF  SURGERY 

the  predisposition  to  secondary  hemorrhage,  and  the  time,  care, 
and  personnel  needed  to  make  it  effective;  hence  despite  the  virtues 
of  Dakin's  solution  as  a  germicide,  and  as  a  cleansing  agent  in  the 
presence  of  sloughing,  various  substitutes  have  been  proposed,  the 
most  important  of  which  is  dichloramin-T. 

Dichloramin-T  (Dakin's  oil)  is  a  solution  of  toluene  parasul- 
phondichloramin  in  chlorinated  paraffin  (chlorcosane) .  The  chlorin 
is  ^slowly  liberated  over  a  period  of  from  18  to  24  hours,  instead 
of  3  to  7  minutes,  as  with  the  Dakin's  solution.  It  is  usually  non- 
irritating  to  the  skin,  and  may  be  kept  for  one  month  with  only  25 
per  cent,  decomposition.  Water,  alcohol,  hydrogen  peroxid,  and 
metal  should  not  come  in  contact  with  the  solution. 

Lee's  technic  for  treating  wounds  with  Dakin's  oil  consists  in 
mechanical  disinfection  as  in  the  Carrel  method.  The  skin  is  cleansed 
with  soap,  water  and  ether,  and  the  wound  filled  with  a  5  per  cent, 
solution.  If  there  is  a  dependent  drain,  this  is  plugged  until  after 
the  oil  has  been  poured  into  the  cavity.  The  oil  is  reapplied  every 
24  hours,  and,  in  order  to  prevent  its  absorption  into  the  dressing, 
only  four  layers  of  gauze  are  used  to  cover  the  wound.  Further, 
the  dressing  should  not  be  impervious,  otherwise  the  confined  dichlor- 
amin  becomes  irritating  to  the  skin.  Relatively  clean  wounds  are 
sutured  at  once,  others  are  closed  secondarily  after  bacteriologic 
examinations  have  proved  them  to  be  clinically  sterile. 


CHAPTER  IV 
SURGICAL  TECHNIC 

An  operation  is  performed  with  greater  comfort  to  the  surgeon, 
and  greater  safety  to  the  patient,  in  a  hospital  than  in  a  private 
house.  A  well-equipped  hospital  is  supplied  with  an  anesthetizing 
room,  an  operating  room,  a  recovery  room,  and  rooms  for  the  sur- 
geons and  nurses  to  change  their  clothing.  The  most  essential  factor 
in  an  anesthetizing  room  is  that  it  be  well  lighted,  in  an  operating 
room  that  it  may  be  easily  and  thoroughly  cleansed,  and  in  a  recovery 
room  that  it  has  some  means  of  immediately  summoning  aid  in  an 
emergency.  There  are  also  auxiliary  rooms  for  the  sterilization  of 
the  material  used  during  an  operation,  for  the  storing  of  instruments, 
dressings,  etc. 

Instnunents  are  usually  kept  in  an  air-tight  glass  case,  in  the 
bottom  of  which  are  small  open  compartments,  containing  calcium 
chlorid  for  the  absorption  of  any  moisture  which  may  gain  access 
to  the  closet  and  tarnish  the  instruments.  Instruments  should  be  all 
metal,  with  as  few  corrugations,  indentations,  and  joints  as  possible, 
in  order  to  facilitate  proper  cleaning.  They  are  sterilized  by  boihng 
for  fifteen  minutes  in  water  to  which  has  been  added  sodium  car- 
bonate in  the  strength  of  i  per  cent,  (i^^  dr.  to  the  pint),  for  the 
purpose  ot  preventing  rusting.  As  ebullition  tends  to  dull  sharp 
instruments,  they  should  be  protected  by  a  wrapping  of  cotton  and 
boiled  for  a  shorter  period,  chisels  and  scissors  for  five  minutes,  knives 
and  needles  for  three  minutes;  or  placed  in  a  solution  of  carbolic  acid 
(5  per  cent.),  formalin  (2  per  cent.),  or  alcohol  (95  per  cent.),  for  30 
minutes.  These  solutions  should  be  used  also  for  instruments  with 
wooden  or  ivory  handles,  which  are  cracked  by  boiling.  Instru- 
ments containing  lenses,  e.g.,  the  cystocope,  are  ruined  by  boihng 
and  by  alcohol,  hence  must  be  disinfected  in  a  solution  of  carbolic 
acid  (5  per  cent.)  or  formalin  (2  per  cent.),  all  traces  of  the  chemical 
being  removed  subsequently  by  washing  with  sterile  water,  par- 
ticularly if  the  instrument  is  to  be  used  in  the  urethra,  or  any  other 
situation  in  which  an  active  germicide  might  do  harm.  The  sterilizer 
consists  of  a  copper  tray,  with  a  securely  fitting  lid,  and  a  perforated 
false  bottom  with  handles;  the  false  bottom  prevents  injury  to  the 

59 


6o  MANUAL  OF  SURGERY 

instruments  due  to  the  exposure  to  the  direct  intense  heat  on  the 
floor  of  the  sterilizer,  and  facilitates  their  removal  at  the  completion 
of  boiling,  the  bottom  being  lifted  from  the  sterilizer  by  means  of 
hooks  passed  through  the  handles  of  the  false  bottom.  After  sterili- 
zation instruments  may  be  placed  in  a  tray  containing  sterile  water 
or  spread  on  a  dry  sterile  sheet;  in  either  case  they  should  be  covered 
with  sterile  towels  until  the  operation  is  begun.  At  the  completion 
of  an  operation  the  instruments  should  be  scrubbed  with  soap  and 
water,  sterilized,  and  dried,  before  replacing  them  in  the  closet. 

Sutures  and  Ligatures.^ — Silkworm  gut,  or  fishing  gut,  is  the  thread 
drawn  from  the  silkworm  killed  when  ready  to  spin  the  cocoon.  It 
is  strong,  smooth,  readily  tied  in  a  secure  knot,  and  is  easily  sterilized 
by  boiling.  In  many  hospitals  it  is  placed  in  long  glass  tubes,  which 
are  securely  corked,  and  boiled.  It  is  then  ready  for  instant  use, 
the  tube  being  submerged  in  bichlorid  or  carbolic  acid  solution  before 
being  uncorked.  With  the  latter  method,  however,  it  is  desirable  to 
soak  the  silkworm  gut  in  boiling  water  for  a  few  minutes  before 
using,  in  order  to  render  it  pliable.  As  silkworm  gut  is  not  absorb- 
able, it  is  used  only  on  surfaces  from  which  it  may  be  subsequently 
removed,  and  as  it  stiffens  while  drying,  it  is  not  used  in  such  regions 
as  the  axilla,  perineum,  etc.,  without  shotting,  as  the  ends  might 
occasion  discomfort  by  pricking  the  tissues. 

Silk  is  plaited,  floss,  or  twisted.  It  is  strong,  very  pliable,  and 
may  be  tied  in  a  firm  knot.  It  may  be  sterilized  by  boiling  in  water 
for  a  half  hour.  This  diminishes  the  strength  of  the  silk,  however, 
and  a  better  method  is  to  place  the  material,  wound  on  glass  spools, 
in  a  test  tube  plugged  with  cotton;  the  tube  is  then  placed  under  lo 
pounds'  pressure  in  an  autoclave  for  one-half  hour,  and  the  process  is 
repeated  the  following  day,  and  again  on  the  third  day  {fractional 
sterilization),  the  theory  being  that  any  spores  v/hich  may  have 
escaped  destruction  during  the  first  sterilization  will  have  developed 
into  adults  by  the  second  or  third  day,  and  will  then  be  more  easily 
killed.  Silk  is  used  most  often  for  suturing  the  stomach  and  the 
intestine.     It  is  not  absorbable. 

Catgut  comes  from  the  submucous  coat  of  the  sheep's  intestine. 
Being  absorbable,  it  is  generally  used  for  ligatures  and  for  buried 
sutures.  After  being  put  into  the  tissues  it  swells  and  tends  to  be- 
come untied,  so  that  it  should  always  be  tied  in  three  knots  and  the 
ends  left  at  least  ^-^  inch  long.  It  may  be  sterilized  by  one  of  a 
number  of  different  methods;  boiling  in  alcohol,  cumol,  or  xylol,  and 
sterilization  by  dry  heat  are  efficient,  but  require  special  apparatus. 
The  following  methods  are  simple  and  reliable: 


SURGICAL  TECHNIC  6 1 

Claudius  uses  iodized  catgut.  After  the  raw  catgut  has  been 
wound  on  a  glass  spool  it  is  soaked  for  eight  days  in  a  solution  of  one 
part  of  iodin  and  one  part  of  potassium  iodid  in  loo  parts  of  water. 
Before  using  it  is  placed  in  a  3  per  cent,  solution  of  carbolic  acid  or 
in  sterile  salt  solution,  to  remove  the  surplus  iodin.  Unused  catgut 
may  be  replaced  in  the  iodin  solution.  Catgut  thus  prepared  is 
absorbed  in  from  12  to  16  days,  according  to  its  size.  To  render  the 
gut  less  absorbable,  soak  it  in  a  i  to  2000  aqueous  solution  of  chromic 
acid  for  24  hours  before  sterilization. 

Congdon  uses  a  modilication  of  Iloffmeistcys  method ;  he  winds  raw 
catgut  on  a  glass  cylinder  in  a  single  layer,  and  places  it  in  a  3  per 
cent,  solution  of  formalin  for  from  ij^^  hours  to  4  hours,  according 
to  the  size  of  the  gut.  After  it  has  been  washed  in  running  water  for 
the  same  length  of  time  that  it  has  been  in  the  formalin  solution  it  is 
dried  in  the  open  air  and  stored  away  for  future  use.  Catgut  pre- 
pared by  this  method  may  be  boiled  like  silk.  When  it  is  desired 
to  have  the  catgut  resist  absorption  for  a  longer  period,  a  5  per  cent, 
solution  of  formalin  is  used  instead  of  the  3  per  cent,  solution,  and 
the  gut  is  left  in  this  solution  twice  as  long  as  that  stated  for  the  3 
per  cent,  solution;  it  is  then  washed  in  running  water  for  the  same 
length  of  time  that  it  has  been  submerged  in  the  formahn  solution. 
By  the  latter  method  No.  4  gut  will  resist  absorption  for  from  four  to 
six  weeks. 

Bartlett's  Method. — The  catgut  is  rolled  into  little  coils,  which  are 
strung  on  a  thread  and  suspended  in  a  beaker  glass,  without  touching 
the  sides  or  bottom,  by  bringing  the  ends  of  the  thread  through  a  small 
opening  in  a  pasteboard  cover,  which  is  placed  on  the  receptacle. 
The  same  opening  admits  a  thermometer,  the  bulb  of  which  is  on  a 
level  with  the  topmost  coils.  The  catgut  is  covered  with  liquid 
petrolatum,  the  temperature  of  which  is  gradually  raised  to  2i2°F. 
by  placing  the  beaker  in  a  sand  bath.  After  12  hours  the  tempera- 
ture is  increased  to  3oo°F.  in  the  course  of  an  hour,  and  then  the  oil 
is  allowed  to  cool.  After  allowing  the  superfluous  oil  to  drop  from 
the  catgut,  the  coils  are  placed  until  needed  in  a  i  per  cent,  solution 
of  iodin  in  Columbian  spirits.  This  method,  as  modified  by  Lee,  is 
employed  in  the  Pennsylvania  and  Jefferson  Hospitals.  Lee  drys 
the  gut  in  a  dry  air  sterilizer,  at'ioo°C.,  for  15  minutes,  then  covers 
it  with  liquid  petrolatum  and  raises  the  temperature  to  i4o°C., 
v/here  it  is  maintained  for  15  minutes.  At  the  end  of  12  hours  the 
temperature  is  again  raised  to  i40°C.  and  there  kept  for  15  minutes. 
The  gut  is  preserved  in  a  }{q  per  cent,  solution  of  iodin  in  alcohol 
(95  per  cent.). 


62  MANUAL  OF  SURGERY 

Kangaroo  tendon  is  obtained  from  the  tail  of  the  kangaroo, 
and  may  be  prepared  in  the  same  manner  as  catgut.  When  chromi- 
cized  it  may  not  be  absorbed  by  the  tissues  for  two  months.  It 
is  used  for  suturing  bone,  or  when  an  absorbable  suture  which 
will  last  a  long  time  is  desired. 

Some  surgeons  employ  living  strips  of  fascia  from  the  margins 
of  the  wound  which  they  desire  to  close. 

Silver  wire  may  be  used  for  suturing  bone;  care  being  taken 
in  twisting  the  ends  of  the  wire,  lest  it  break.  Although  silver 
wire  is  said  to  have  antiseptic  properties,  it  frequently  causes 
suppuration  and  sinus  formation  when  allowed  to  remain  in  the 
tissues  for  a  long  time,  and  should  very  rarely  be  used  except  for 
the  indication  just  mentioned.  Iron  wire  has  been  recommended 
as  a  substitute  for  silver  wire  in  bone  work,  as  it  is  not  so  easily 
broken;  aluminum  bronze  wire,  which,  unlike  silver  or  iron,  is  ulti- 
mately absorbed,  has  been  utilized  for  the  same  purpose;  these  wires 
may  be  sterilized  by  boiling. 

Horsehair  may  be  used  for  the  nice  approximation  of  skin  where 
there  is  no  tension ;  it  may  be  boiled  in  water. 

Pagenstecher^s  celluloid  thread  is  linen  thread  impregnated  with 
celluloid;  it  has  the  advantages  of  silkworm  gut,  as  well  as  great 
flexibility. 

Dressings  are  commonly  made  of  cheesecloth,  or  gauze.  Cotton 
or  any  material,  however,  which  will  absorb  fluids  and  which  may 
be  sterilized,  may  be  used  for  this  purpose.  The  sizing  should  be 
removed  from  cheesecloth  by  boiling  in  a  solution  of  carbonate  of 
soda,  but  in  the  material  coming  from  a  surgical  house  this  process 
has  already  been  effected.  The  material  is  cut  into  suitable  lengths 
for  various  operations,  folded,  and  wrapped  in  two  covers  of  drilling 
or  heavy  muslin,  which  are  secured  by  a  pin.  These  packages  are 
sterilized  under  lo  pounds'  pressure  for  forty-five  minutes,  and 
are  kept  in  covered,  sterilized  glass  jars  until  required.  Antiseptic 
dressings  are  prepared  by  soaking  gauze  in  solutions  of  various 
antiseptics. 

Sponges,"  in  surgical  parlance,  are  small  pads  of  gauze.  They 
are  put  up  in  packages,  each  of  which  contains  a  definite  and  an 
invariable  number  of  pads,  usually  lo,  so  as  to  facilitate  counting 
at  the  time  of  operation.  For  intraabdominal  work  large  gauze 
pads,  six  or  more  inches  square,  consisting  of  six  layers  of  gauze, 
are  employed  to  isolate  the  field  of  operation.  To  one  corner  of 
each  pad  is  sewed  a  piece  of  tape,  which  emerges  from  the  wound 


SURGICAL  TECHNIC  63 

and  is  secured  l)y  a  heniostat,  in  order  that  it  shall  not  ])e  forgotten. 
A  better  plan  is  to  pre])are  a  pad  four  yards  long,  six  inches  broad, 
and  four  layers  in  thickness;  as  much  of  this  as  may  be  necessary 
is  packed  into  the  abdomen,  and  the  end  allowed  to  protrude  from 
the  wound ;  it  is  then  definitely  known  that  but  one  piece  of  gauze 
is  within  the  abdomen.  All  of  these  pads,  as  well  as  gauze  drains, 
should,  in  order  to  prevent  the  detaching  of  loose  threads,  be  folded, 
or  folded  and  sewed,  in  such  a  way  that  the  raveled  edges  of  the 
gauze  do  not  come  in  contact  with  the  wound ;  and  all  are  sterilized 
and  preserved  like  dressings. 

Iodoform  gauze  is  prepared  by  mixing  4  ounces  each  of  iodoform, 
glycerin,  and  alcohol,  and  5  gr.  of  bichlorid  of  mercury;  sterile 
gauze  is  soaked  in  this  mixture,  allowed  to  drip  till  almost  dry,  and 
then  stored  in  covered,  disinfected  glass  jars. 

Caps,  masks,  gowns,  sheets,  and  towels,  are  sterilized  with  the 
gauze.  Basins,  pitchers,  instrument  trays,  scrubbing  brushes,  and 
glass  drainage  tubes  should  be  boiled.  Articles  made  of  hard  rubber, 
such  as  pessaries,  syringe  nozzles,  etc.,  should  be  washed  with  soap  and 
water,  and  disinfected  in  a  i  to  500  bichlorid  of  mercury  solution. 
Soft  rubber,  e.g.,  drainage  tubes,  catheters,  etc.,  should  be  boiled  in 
plain  water  for  five  minutes,  and  stored  in  bichlorid  of  mercury  solu- 
tion. Varnished  catheters  may  be  sterilized  in  formalin  solution  (2 
per  cent) .  Instruments  containing  leather,  such  as  the  hypodermatic 
syringe,  are  sterilized  by  soaking  in  a  solution  of  carbolic  acid.  Hypo- 
dermatic syringes  with  glass  or  asbestos  pistons  may  be  boiled  and  are 
much  safer,  from  a  bacteriologic  standpoint,  than  the  o.lder  variety. 
Lister's  oiled  silk,  rubber  tissue  (thin  sheets  of  gutta-percha),  rubber 
dam,  and  wax  or  paraffin  paper  are  sterilized,  after  washing,  by 
soaking  in  bichlorid  of  mercury  solution.  As  heat  shrivels  rubber 
tissue,  care  should  be  taken  to  have  the  solution  cool.  Silver  foil 
is  sterilized  by  dry  heat. 

Physiologic  or  normal  salt  solution  (.8  per  cent.,  or  i  dr.  of  salt 
to  the  pint  of  water),  called  physiologic  or  normal  because  it  is 
isotonic  with  the  blood  serum,  is  filtered  into  clean  glass  flasks, 
which  are  plugged  with  cotton  and  then  boiled.  Perhaps,  in  view 
of  the  recent  observations  concerning  the  harmfulness  of  the  proteid 
products  of  dead  organisms  in  old  water,  it  would  be  well  to  insist 
that  salt  solution,  at  least  when  it  is  to  be  used  hypodermically  or 
intravenously,  be  made  from  freshly  distilled  water. 

Water,  too,  must  be  filtered  as  well  as  boiled.  In  hospitals  the 
water-sterilizer  outfit  consists  of  two  reservoirs,  one  for  hot  and 
one  for  cold  water.     Each  has  a  filtering  attachment.     The  water 


64  MANUAL  OF  SURGERY 

is  boiled  for  20  minutes,  under  a  pressure  of  15  pounds  (24o°F.). 
The  faucets,  when  not  in  use,  must  be  covered  with  sterile  gauze. 

The  surgeon,  the  assistants,  and  the  nurses  should  bathe 
daily,  keep  the  teeth  in  good  order,  and  not  come  in  contact  with 
contagious  diseases.  No  one  with  acute  tonsillitis,  or  an  infected 
wound  or  furuncle  on  the  hands  or  forearms,  should  take  part  in 
an  operation.  The  surgeon  should  guard  his  hands  from  the  grosser 
forms  of  contamination  at  all  times;  he  should  never  open  an  abscess 
or  dress  suppurating  wounds  without  wearing  rubber  gloves,  and 
he  should  put  on  a  rubber  glove  before  making  a  rectal  or  a  vaginal 
examination.  He  should  avoid  carrying  heavy  bags,  restraining  a 
patient  who  is  being  anesthetized,  and  lifting  a  patient  from  the 
litter  to  the  operating  table,  lest  his  hands  tremble  during  the 
operation.  At  the  time  of  operation  the  surgeon,  the  assistants, 
and  the  nurses  should  wear  sterile  suits  of  duck  or  linen,  sterile  caps, 
and  sterile  masks. 

Disinfection  of  the  hands  and  forearms  is  effected  by  scrubbing 
with  soap  and  running  hot  water.  The  brush  should  have  been 
sterilized  by  boiling  just  before  use,  and  special  attention  should 
be  given  to  folds  and  creases,  and  to  the  spaces  beneath  and  around 
the  nails.  The  nails  should  be  trimmed,  the  subungual  spaces 
cleansed  with  a  nail  cleaner,  and  the  scrubbing  continued,  accord- 
ing to  different  surgeons,  for  from  five  to  fifteen  minutes.  The 
longer  period  is  preferable,  and  should  be  timed  by  the  clock.  Rings 
and  bracelets  must,  of  course,  be  removed  before  the  hands  are 
washed.     The  next  step  varies  with  the  surgeon. 

In  the  Fiirhringer  method,  the  hands  are  scrubbed  in  absolute 
alcohol  for  one  minute,  then  soaked  and  scrubbed  in  bichlorid  of 
mercury  solution  i  to  1000  for  at  least  one  minute,  special  attention 
being  given  to  the  nails.  Many  surgeons  now  dispense  with  the 
bichlorid  Vv^ash  and  scrub  the  hands  in  70  per  cent,  alcohol  for  five 
minutes.  Absolute  alcohol  is  less  bactericidal,  as  it  coagulates  al- 
bumin, thus  interfering  with  its  penetration.  Of  the  various  other 
antiseptics  which  have  been  proposed  for  the  hands,  most  are  too 
irritating  to  the  skin.  After  disinfecting  the  hands  a  sterile  gown 
with  sleeves  reaching  the  wrists  should  be  put  on. 

As  absolute  sterihty  of  the  hands  cannot  be  secured,  most 
surgeons,  after  employing  one  of  the  methods  given  above,  use 
rubber  gloves.  Rubber  gloves  are  sterilized  by  washing  mth  soap 
and  water,  and  boiling  in  a  i  per  cent,  solution  of  sodium  carbonate 
for  fifteen  minutes.  They  are  drawn  on  the  hands  while  filled  with 
sterile  water,  or  by  using  glycerin  as  a  lubricant,  or  they  may  be 


SURGICAL  TECHNIC  65 

dried,  and  slipped  on  with  ease  after  the  interior  has  been  dusted 
with  sterile  talcum.  Oil  should  not  be  used  for  lubrication,  as  it 
injures  the  rubber.  The  cuffs  of  the  gloves  should  be  turned  down 
before  sterilization,  and  in  putting  the  gloves  on  the  surgeon  should 
seize  the  cuff  of  the  left  glove  at  its  point  of  reflection,  pull  the 
glove  on  the  left  hand,  and  then  insert  the  fingers  of  the  left  hand 
beneath  the  reflected  cuff  of  the  right  glove  and  so  adjust  it;  the 
cuffs  are  then  turned  back  over  the  sleeves  of  the  gown;  thus 
the  bare  lingers  never  come  in  contact  with  the  outside  of  the  gloves. 
Gloves,  however,  are  not  ideal;  they  impair  sensation,  necessitate 
very  firm  pressure  in  holding  a  slippery  structure  like  the  intestine, 
and  tend  to  make  an  operator  slovenly  in  the  disinfection  of  his 
hands;  they  also  cause  perspiration,  thus  washing  from  the  deeper 
layers  of  the  skin  bacteria,  which  gain  entrance  to  the  wound  through 
punctures  and  tears  in  the  gloves,  an  accident  which  demands  a 
fresh  glove,  after  washing  the  hand  in  bichlorid  solution. 

The  Patient. — For  preparation  for  anesthesia  see  section  on 
"Anesthesia."  The  dangers  common  to  all  operations  are  those 
of  anesthesia,  hemorrhage,  shock,  and  infection.  Special  dangers 
of  individual  operations  receive  mention  with  the  description  of 
the  various  operations.  Whenever  possible  the  period  of  observation 
elapsing  before  operation  should  be  sufficiently  long  to  allow  a 
complete  diagnosis  to  be  made.  The  history  is  taken,  and  a  thorough 
examination,  especially  of  the  heart,  lungs,  urine,  and  blood,  is  made. 
The  diet  should  be  free  of  vegetables  and  consist  principally  of 
albumins,  in  order  to  leave  little  residue  in  the  intestines,  which 
are  cleared  by  laxatives.  This  prevents  autointoxication,  and  in 
abdominal  work  renders  the  intestines  docile,  so  that  they  may 
be  kept  from  the  operative  field  by  gauze  packing.  Vigorous 
catharsis  is  seldom  necessary,  and  may  be  harmful,  especially  in 
the  feeble,  in  whom  it  increases  the  exhaustion.  Both  laxatives 
and  purgatives  are  contraindicated  in  menacing  perforation,  e.g., 
acute  appendicitis,  because  they  may  occasion  the  perforation; 
in  actual  perforation,  because  they  increase  the  extravasation; 
in  peritonitis,  because  owing  to  the  active  peristalsis,  they  diffuse 
the  infection;  in  intestinal  obstruction,  because  they  cause  useless 
pain,  and  sometimes  perforation;  immediately  before  operations 
on  the  colon,  because  they  render  the  contents  of  this  viscus  fluid, 
hence  more  apt  to  leak;  and  just  before  operations  on  the  rectum, 
because  they  flood  the  area  of  operation  with  liquid  feces.  Before 
operations  on  the  mouth,  esophagus,  and  gastrointestinal  tract 
the  number  of  bacteria  in  the  alimentarv  canal  mav,  aside  from 


66  MANUAL  OF  SURGERY 

purgation,  be  diminished  by  removing  car'ous  teeth  and  tartar, 
frequently  rinsing  the  mouth  with  an  antiseptic  wash,  and  sterihzing 
(cooking)  all  food.  The  influence  of  intestinal  antiseptics  is  so 
slight  as  to  be  negligible.  Hexamethyleamin,  because  of  its 
antiseptic  effect  upon  the  bile,  the  urine,  and  the  cerebrospinal 
fluid,  may  be  administered  previous  to,  as  well  as  after,  operations 
involving  the  biliary  tract,  the  urinary  apparatus,  and  the  central 
nervous  system.  The  patient  is  given  a  daily  soap  and  water 
bath,  and  should,  in  order  to  prevent  "colds,"  wear  an  undershirt 
in  bed,  if  so  accustomed. 

The  day  before  operation  the  part  to  be  operated  upon  is  shaved, 
and  then,  after  disinfection  of  the  hands,  it  is  surrounded  with  sterile 
towels,  and  scrubbed  with  soap  and  water,  using  a  sterile  brush 
with  soft  bristles,  or  if  the  skin  is  tender  a  piece  of  gauze.  Special 
attention  is  given  to  folds  and  creases  in  the  skin,  and  to  such 
places  as  the  umbilicus.  It  is  important  to  scrub  not  only  the 
immediate  region  of  the  proposed  wound,  but  also  neighboring 
regions,  e.g.,  for  a  brain  operation,  not  only  the  head,  but  also  the 
neck  and  ears,  and  for  a  breast  amputation,  not  only  the  breast, 
but  also  the  neck,  axilla,  arm,  opposite  breast,  and  the  upper  part 
of  the  abdomen.  For  an  abdominal  operation  the  disinfection 
should  extend  around  to  the  spine,  up  to  the  breasts,  and  down  to 
the  pubes,  including  the  upper  part  of  the  thighs;  for  a  gynecological 
operation  it  is  necessary  to  disinfect  also  the  vagina.  After  scrubbing 
with  soap  and  water,  the  skin  is  rubbed  with  alcohol  (70  per  cent.), 
in  order  to  dissolve  the  sebaceous  matter  and  fat  in  the  mouths  of 
the  glands,  and  thus  clear  the  way  for  the  bichlorid  of  mercury 
solution,  I  to  1000,  with  which  the  part  is  next  scrubbed.  In 
children,  in  adults  with  sensitive  skins,  as  well  as  on  the  scalp,  a 
I  to  2000  solution  should  be  employed.  With  hard  and  filthy  skin, 
such  as  is  often  found  on  the  feet,  a  soap  poultice,  made  by  soaking 
a  thick  pad  of  gauze  in  soap  suds,  should  be  applied  for  many  hours 
before  the  disinfection.  Gauze  soaked  in  bichlorid  of  mercury 
(i  to  2000)  and  covered  with  waxed  paper,  or,  better,  a  dry  sterile 
dressing,  is  appHed  to  the  disinfected  region  until  the  time  of  oper- 
ation, when  the  whole  procedure  is  repeated.  Some  surgeons  omit 
the  preliminary  scrubbing,  others  claim  that  the  scrubbing  at  the 
time  of  operation  is  objectionable,  in  that  it  uncovers  bacteria  in 
the  skin  by  loosening  fresh  layers  of  epidermis;  an  increasing  number 
are  painting  the  skin  with  tincture  of  iodin  (3  per  cent.)  the  day 
before  and  again  at  the  time  of  operation.  Grossich,  the  originator 
of  the  iodin  method,  removes  the  hair  immediately  before  operation 


SURGICAL  TECHNIC  67 

by  (lr\-  shavinJ,^  claiming  that  water  swells  the  superficial  layers 
of  the  epidermis  and  interferes  with  i)enetiation  of  the  iodin;  he 
then  applies,  without  prehminary  scrubbing,  the  official  tincture  of 
iodin,  which  is  allowed  to  dry  spontaneously.  Iodin  is  an  admirable 
antiseptic  which  penetrates  the  epidermis  and  fixes  the  bacteria  in 
the  skin.  Its  disadvantages  are  that  it  may  produce  irritation 
of  the  skin  of  the  patient  and  the  eyes  of  the  operator,  and  that  it 
may  cause  intraperitoneal  adhesions  after  laparotomies  in  which 
the  viscera  are  brought  out  on  the  abdominal  wall.  The  last 
objection  loses  its  force  if  the  skin  is  completely  covered  with  towels 
during  the  operation.  The  ear  may  be  sterilized  by  prolonged 
syringing  with  a  carbolic  solution,  i  to  loo,  or  with  a  bichlorid  of 
mercury  solution,  i  to  2000;  the  nose  by  spraying  with  Dobell's 
solution,  followed  by  carbolic  acid,  i  to  loo;  the  mouth  by  having 
the  teeth  put  in  order  and  tartar  removed  by  a  dentist,  and  by  the 
use  of  a  tooth  powder  and  brush  several  times  a  day,  followed  by 
rinsing  with  a  carbolic  acid  solution,  i  to  100;  and  the  bladder  by 
irrigation  with  potassium  permanganate,  i  to  5000,  argyrol,  i  to 
1000,  or  by  a  saturated  solution  of  boric  acid.  The  vagina  is  scrub- 
bed with  a  piece  of  gauze,  with  soap  and  water,  then  copiously 
douched  with  bichlorid  of  mercury  solution,  i  to  4000.  The  rectum 
may  be  cleansed  of  fecal  matter  by  an  enema  of  soap  and  water, 
then  irrigated  with  salt  solution. 

A  nervous  sedative  may  be  administered  the  night  preceding 
operation,  if  the  patient  is  unable  to  sleep.  No  food  should  be 
given  for  at  least  six  hours  before  operation,  in  order  that  the  stomach 
may  be  empty  and  that  vomiting  may  not  occur.  Several  hours 
before  operation  the  rectum  should  be  emptied  with  a  soap  and  water 
enema,  i  pint,  so  that  any  stimulating  or  nutritious  fluids  may  be 
absorbed  in  case  their  injection  becomes  necessary.  However,  if 
the  rectum  itself  is  to  be  subjected  to  operation,  it  should,  for  the 
reason  mentioned  above,  be  cleansed  not  less  than  24  hours  previ- 
ously. Immediately  before  administering  the  anesthetic  the  patient 
should  pass  urine  or  be  catheterized,  so  that  voiding  will  not  occur 
on  the  table,  so  that  there  will  be  no  danger  of  injury  to  the  bladder 
in  an  abdominal  operation,  and  so  that  the  surgeon  will  know  the 
exact  quantity  of  urine  secreted  subsequent  to  operation.  Before 
going  to  the  operating  room,  those  parts  of  the  chest,  abdomen, 
and  limbs  which  are  not  to  be  operated  upon,  should  be  covered 
with  a  sterilized  shirt,  leggings,  etc.,  to  protect  the  patient  from 
draughts. 

In  an  emergency  in  which  the  patient  is  admitted  immediately 


68  MANUAL  OF  SURGERY 

before  the  operation,  the  same  precautions  regarding  the  bladder 
and  rectum  should,  as  a  rule,  be  observed,  and  the  field  of  operation 
disinfected,  after  the  patient  has  been  anesthetized,  by  dry  shaving 
and  the  application  of  tincture  of  iodin.  In  cases  of  intestinal 
obstruction  it  is  of  the  greatest  importance  to  wash  out  the  stomach 
pievious  to  anesthetization,  to  prevent  suffocation  by  the  large 
quantities  of  fetid  fluid  which  are  regurgitated  while  the  patient  is 
unconscious. 

The  Operation. — In  all  "clean  cases,"  and  even  in  septic  cases 
in  the  cranium,  chest,  abdomen,  and  joints,  the  surgeon  perfoims 
an  aseptic  operation,  i.e.,  the  preparations  mentioned  above  are 
carried  out,  but  after  the  incision  has  been  made  no  antiseptics  are 
used,  and  the  wound  is  dressed  with  sterile,  not  antiseptic,  gauze. 
In  septic  and  emergency  operations  not  involving  the  cavities  just 
mentioned,  the  surgeon  may  perform  an  antiseptic  operation,  i.e., 
antiseptics  aie  used,  not  only  in  the  preparation  of  the  patient,  but 
also  to  disinfect  the  wound,  and  antiseptic  gauze  is  used  for 
dressings. 

The  operating  table  is  covered  with  a  blanket  wrapped  in  a 
sterile  sheet;  in  special  cases  an  electric  mattress  or  a  number  of 
hot  water  bags  are  used  to  maintain  the  heat  of  the  body.  When 
the  patient  is  placed  on  the  table,  care  should  be  taken  that  the 
arms  are  properly  disposed.  If  the  arm  is  allowed  to  hang  over  the 
edge  of  the  table,  if  the  patient  is  allowed  to  lie  on  the  arm  twisted 
under  the  back,  or  if  the  arms  are  stretched  far  above  the  head  for  a 
prolonged  period,  an  annoying  paralysis  may  result.  If  the  arms 
rest  alongside  of  the  patient,  there  is,  with  some  operating  tables, 
danger  that  they  may  be  injured  when  the  patient  is  lowered  from 
the  Trendelenburg  posture,  or  when  the  stage  for  arching  the  spine 
forwards  in  biliary  operations  is  elevated  or  lowered.  In  cases  not 
involving  the  chest  or  upper  abdomen  the  arms  may  be  folded 
across  the  chest  and  secured  by  turning  back  the  shirt.  In  ope- 
rations on  the  upper  abdomen  the  arms  should  be  elevated  not  higher 
than  a  right  angle  with  the  body  and  the  hands  secured  above  the 
head.  Never  should  the  arms  be  so  tied  that  they  may  not  be 
readily  freed  for  the  purpose  of  artificial  respiration  should  it  sud- 
denly become  necessary.  After  the  part  to  be  operated  upon  has 
been  exposed  by  a  nurse  whose  hands  are  not  disinfected,  the  sur- 
geon's assistant  places  sterile  towels,  over  the  adjacent  clothing, 
and  redisinfects  the  part  by  the  process  already  given.  All  the 
clothing  of  the  patient  is  now  covered  by  fresh  sterile  sheets  or 
towels.     It  is  our  custom,  as  soon  as  the  incision  is  made,  to  fasten 


SURGICAL  TECHNIC  69 

sterile  towels  to  the  fascia  or,  in  an  abdominal  operation,  to  the 
peritoneum  with  catgut  sutures,  thus  excluding  the  skin  completely 
from  the  operative  field.  In  order  to  avoid  fatigue  of  the  eyes  and, 
especially  in  class  work,  bring  the  operative  field  into  greater  relief, 
we  employ,  following  the  advice  of  Sherman,  black,  instead  of 
white,  sheets  and  towels.  In  operations  about  the  face  or  neck  the 
hair  should  be  covered  by  a  sterile  rubber  cap  or  a  sterile  towel. 
In  operations  approaching  the  nose  and  mouth  it  is  important  also 
that  the  anesthetizer  disinfect  his  hands,  wear  a  sterile  gown,  and 
use  a  sterile  piece  of  gauze,  a  cone  wrapped  in  a  sterile  towel,  or  a 
vaporizing  apparatus,  for  the  anesthetic.  As  a  rule  one  assistant 
is  sufficient  for  almost  any  operation;  the  fewer  hands  that  come 
in  contact  with  the  wound  the  less  the  danger  of  infection.  At 
least  three  nurses  are  commonly  on  duty  during  an  operation;  one 
nurse  attends  to  the  sutures  and  ligatures,  a  second  takes  care  of 
the  sponges  and  dressings,  and  a  third,  "unsterile  nurse,"  exposes 
the  field  of  operation,  assists  the  etherizer,  gets  additional  instruments 
that  may  be  called  for,  and  does  whatever  else  may  be  necessary 
that  one  with  disinfected  hands  cannot  do.  Before  and  after 
operations  involving  the  abdomen  or  other  large  cavity,  not  only 
sponges  and  pads,  but  also  instruments  and  needles,  should  be 
carefully  counted,  to  make  sure  that  none  has  been  left  behind. 
Incisions  should  be  clean-cut  and  of  equal  depth  throughout. 
The  way  the  knife  is  held  to  make  incisions  is  illustrated  in  Figs.  1 2  to 
17.  Tearing  the  tissues  by  blind  and  blunt  dissection  should  be 
avoided  as  much  as  possible,  as  bruising  is  more  likely  to  be  followed 
by  suppuration.  Large  blood  vessels  should  be  caught  with  hemo- 
stats,  or  ligated,  before  division;  vessels  too  small  to  be  recognized 
should  be  caught  quickly  as  soon  as  divided,  the  forceps  grasping 
not  a  large  amount  of  tissue,  but  the  bleeding  point  alone.  Under  no 
circumstances  should  the  skin  be  crushed  with  hemostatic  forceps. 
The  assistant  keeps  the  wound  free  of  blood,  not  by  scrubbing,  but 
by  quickly  mopping  with  a  gauze  sponge.  As  soon  as  an  instrument 
has  been  used  it  should  be  washed  in  sterile  water  and  replaced  in  the 
instrument  tray.  At  frequent  intervals  during  the  operation  the 
hands  should  be  washed  in  sterile  water.  When  the  towels  sur- 
rounding the  field  of  operation  become  soiled,  they  should  be  replaced 
or  covered  by  fresh  ones.  Sometimes  at  the  completion  of  the 
operation  it  is  desirable  to  flush  the  wound  with  hot  sterile  water  or 
normal  salt  solution,  to  free  it  from  blood  clots  and  mechanically 
disinfect  it.  At  this  time  it  will  be  found  that  the  smaller  vessels 
which  have  been  clamped  do  not  bleed  after  removal  of  the  forceps. 


70 


MANUAL  OF  SURGERY 


Larger  vessels  should  be  ligated  with  catgut;  torsion  is  not,  as  a  rule. 
a  satisfactory  method  for  dealing  with  these  vessels.  If  the  bleeding 
has  not  been  stopped,  clots  will  accumulate  and  infection  be  favored. 
The  deeper  layers  of  the  wound  are  brought  together  with  catgut 
sutures,  the  skin  with  silkworm  gut  ("see  Wounds"). 


Drainage  is  indicated  if  there  is  still  some  bleeding,  if  there  is 
infection,  if  strong  antiseptics  have  been  used,  if  toxic  secretions  are 
likely  to  escape  into  the  wound  (e.g.,  after  partial  thyroidectomy  for 
exophthalmic  goiter),  if  many  large  lymph  vessels  have  been  severed 
(e.g.,  as  in  the  modern  operation  for  carcinoma  of  the  breast),  if  it  is 
desired  to  establish  an  external  fistula  (e.g.,  urinary,  biUary),  or  if  it 


SURGICAL  TECHNIC  7 1 

is  frared  tliat  sutures  i)ut  in  a  hollow  viscus  may  not  hoki.  Drainage 
may  be  effected  by  rubber,  silver,  or  glass  tubes;  by  strands  of  cat- 
gut, horsehair,  or  silkworm  gut;  or  by  strips  of  gauze  or  rubber  tissue. 
In  order  to  prevent  its  adhering  to  the  tissues,  gauze  may  be  sur- 
rounded with  rubber  tissue  (cigarette  drain),  or  impregnated  with 
glycerin,  vaselin,  or  an  antiseptic  ointment.  A  drain  that  sticks 
causes,  when  removed,  pain  and  bleeding,  and  opens  areas  through 
which  septic  absorption  may  occur.  The  writer,  particularly  in 
abdominal  cases,  frequently  employs  the  Mikulicz  drain.  This 
consists  of  a  thin  gauze  bag,  filled  with  a  separate  strip  of  gauze, 
which  may  be  removed  and  the  cavity  irrigated  without  disturbing 
the  bag.  The  bag  remains  in  place  until  it  is  loose.  Vaselinized 
gauze  is  then  employed  to  keep  the  tract  open.  A  drain  should, 
whenever  possible,  be  placed  in  the  most  dependent  part  of  a  wound 
or  cavity.  In  women  the  peritoneal  cavity  may  often  be  drained 
through  the  vagina,  thus  permitting  closure  of  the  abdominal  wound 
as  well  as  facilitating  the  discharge.  The  objections  to  drainage  are 
that  it  delays  union,  produces  a  wider  scar,  invites  infection,  en- 
courages adhesions,  and  in  abdominal  cases  predisposes  to  hernia 
and,  because  of  adhesions,  to  intestinal  obstruction;  intestinal  ob- 
struction is  possible  also  simply  from  the  compression  exerted  by  a 
tube  or  gauze  pack.  A  tube  may  ulcerate  into  a  large  blood  vessel 
and  cause  secondary  hemorrhage,  or  induce  pressure  necrosis  of  the 
intestine  arid  fecal  fistula,  hence  should  rarely  be  used  in  the  vicinity 
of  the  major  arteries  or  veins,  or  in  the  free  abdominal  cavity. 

The  wound  is  dressed  with  sterile  gauze,  and  maintained  in  place 
by  a  suitable  bandage.  Occasionally  in  septic  cases  it  is  desirable  to 
use  antiseptic,  instead  of  sterile,  gauze. 

After  Treatment- — The  patient  is  put  into  a  warm  bed  with  no 
pillow,  and  the  head  turned  to  one  side,  so  that  in  case  vomiting 
occurs,  there  will  be  less  danger  of  the  vomited  material  falling  into 
the  trachea.  In  all  cases  a  physician  or  a  nurse  should  remain  with 
the  patient  until  the  effects  of  the  anesthetic  have  disappeared. 
Shock,  if  present,  should  be  combated  at  once.  If  there  is  non- 
obstructive retention  of  urine  and  it  is  inadvisable  to  allow  the  patient 
to  get  out  of  bed  to  try  to  micturate,  heat  may  be  applied  to  the 
hypogastrium  or  warm  water  poured  over  the  external  genitals. 
Spontaneous  urination,  according  to  Franck,  often  follows ,  within 
20  or  30  minutes,  the  injection  of  from  15  to  20  cc.  of  glycerin  into  the 
bladder  through  the  urethra,  without  the  aid  of  a  catheter.  If  this 
"bladder  laxative,"  which  should  not  be  used  if  there  is  acute  cystitis 
or  urethritis,  fails,  a  catheter  may  be  passed  every  eight  hours.     The 


72  MANUAL  OF  SURGERY 

treatment  of  retention  due  to  obstructive  lesions  is  given  in  chapter 
XXIX.     As  a  rule,  even  in  abdominal  cases,  the  patient  may  take, 
as  soon  as  the  post-anesthetic  nausea  has  disappeared,  small  amounts 
of  water,  and,  if  this  is  retained,  increasing  quantities  of  liquid  food. 
Continued  vomiting,   especially   after  abdominal  operations,   is   an 
ominous  sign  (see  "After  Effects"  of  anesthesia).     For  thirst,  when 
the  stomach  must  be  kept  quiet,  an  enema  of  8  oz.  of  water  may  be 
given  every  four  or  six  hours.     In  the  few  cases  in  which  rectal 
injections  actually  cause  nausea,  they  should  of  course  be  discon- 
tinued, and  salt  solution  given  beneath  the  skin.     The  practice  of 
leaving  a  large  quantity  of  salt  solution  in  the  abdomen  after  celi- 
otomy prevents    thirst    and    favors    elimination.     Pain    should    be 
treated,  whenever  possible,  by  removing  the  cause,  e.g.,  by  loosening 
tight  bandages,  relieving  tympanites,  opening  an  infected  wound. 
Analgesics  should  not  be  administered  without  investigation  to  de- 
termine the  reason  for  the  pain.     If  the  cause  cannot  be  found  or 
removed  and  the  suffering  is  great,  the  only  remedy  of  value  is 
morphin,  which,  however,  must  be  used  with  great  caution.     Nurses 
should  be  warned  that  postoperative  pain  in  the  leg  may  be  due  to 
phlebitis,  and  that  massage,  which  might  liberate  emboli,  should 
never  be  employed  without  the  advice  of  the  physician.     Nervous- 
ness may  be  allayed  by  the  bromides,  given  per  rectum  if  oral  ad- 
ministration is  contraindicated.     Insomnia  not  due  to  pain  is  treated 
by  hypnotics  like  trional  and  sulphonal.     Fever  after  operation  is 
considered  in  chapter  XII.     The  character  of  the  pulse  furnishes  a 
surer  index  of  the  patient's  condition  than  the  temperature.     Espe- 
cially during  the  first  twenty-four  hours  one  should  watch  for  the 
symptoms  of  hemorrhage   (q.v.).     Backache  may  be  due  to  renal 
congestion,  muscle  strain,  or  distension  of  the  colon,  hence  may  be 
relieved  by  hot  applications,  increasing  the  urinary  output,  support 
to  the  back,  or  by  securing  a  movement  of  the  bowels.     If  the  bowels 
do  not  move  within  48  hours  the  patient  is  usually  given  a  laxative, 
unless  such  is  contraindicated,  e.g.,  after  an  operation  on  the  esoph- 
agus or  the  gastrointestinal  canal.     If  a  laxative  is  ineffective  or 
contraindicated,  an  enema  of  soap  and  water,  i  pint,  is  given.     If 
this  is  unsuccessful,  an  enema  consisting  of  magnesium  sulphate  i  oz., 
glycerin  i  oz.,  turpentine  }-2  oz.^  and  soap  and  water  i  pint,  may  be 
tried.     An  enema  consisting  of  alum  i  oz.,  in  a  pint  of  water,  is  also 
highly  efficient.     The  introduction  of  a  tube  into  the  rectum,  or  the 
administration   of   asafetida   suppositories,    grains   v,    every   three 
hours,    will   often   be   followed    by   the   expulsion   of   gas.     These 
measures  are  of  special  importance  after  an  abdominal  operation. 


SURGICAL  TECHNIC  7,5 

particularly  when  the  constipation  is  associated  with  tympany  and 
vomiting,  which  often  indicate  a  beginning  peritonitis  or  intestinal 
obstruction  (chapter  XXVII).  After  the  bowels  have  moved  the 
patient  begins  to  take  liquid  semi-solid  food  in  small  quantities,  and  as 
convalescence  progresses  the  quanity  and  variety  are  increased,  until 
finally  the  regular  diet  is  reached.  The  dressings  are  changed  when 
they  become  displaced;  soiled  with  wound  fluid,  or  with  other  dis- 
charges, e.g.,  from  the  nose,  mouth,  rectum,  va.gina,  or  urethra; 
when  it  is  desirable  to  remove  drainage  or  stitches;  and  when  there 
are  signs  of  suppuration.  They  should  not  be  disturbed  unless  there 
is  some  definite  indication,  as  exposure  of  the  wound  always  increases 
the  risk  of  infection.  If  a  drain  has  been  used  because  of  hemorrhage, 
it  may  be  removed  at  the  end  of  twenty-four  or  forty-eight  hours, 
and  not  replaced.  Drainage  for  infection  usually  demands  frequent 
dressings.  The  stitches  may  be  removed  in  a  week  or  ten  days, 
according  to  the  amount  of  support  needed.  A  stitch  abscess  usually 
makes  its  appearance  in  from  five  to  ten  days;  it  requires  the  removal 
of  the  stitch  and  drainage  of  the  abscess  cavity.  The  sequelae  of 
special  operations  are  considered  with  the  various  operations. 

Operation  in  a  Private  House.^Excepting  in  an  emergency,  the 
proposed  operating  room  should  be  carefully  prepared.  It  should  be 
well  hghted,  and  heated  by  steam,  hot  water,  or  hot  air;  there  should 
be  no  exposed  fire  to  provide  dust,  or  to  ignite  the  ether  if  such  be 
used.  A  bath  room  with  hot  and  cold  water  should  be  near,  but 
there  should  be  no  plumbing  in  the  room  itself.  Everything  which 
is  not  necessary  for  the  operation  should  be  removed  from  the  room, 
including  curtains,  shades,  and  carpets.  Wood  work  and  painted 
walls  may  be  scrubbed  with  soap  and  water;  papered  walls  rubbed 
down  with  bread.  At  the  time  of  operation  the  temperature  of  the 
room  should  be  at  least  7o°F.  The  windows  may  be  smeared  with 
soap  to  discourage  inquisitive  neighbors.  If  the  room  is  heated  by 
hot  air,  the  register  should  be  covered  with  a  moist  towel  in  order  to 
catch  the  dust.  In  an  emergency  carpets  and  furniture  should  be 
covered  with  clean  sheets  or  linen,  and  under  no  circumstances 
should  dust  be  stirred  up.  It  is  convenient  to  have  in  the  room  the 
following  articles:  Kitchen-table,  dining- table,  bureau  or  table, 
wash-stand  or  table,  another  small  table,  four  wooden  chairs,  several 
clean  blankets  and  sheets,  at  least  a  dozen  clean  towels,  two  basins,  a 
large  pitcher  of  warm  water,  and  a  bucket  or  slop  jar.  The  kitchen- 
table  serves  for  the  operating  table.  Very  often  this  will  prove 
to  be  too  short,  and  a  smaller  table  will  have  to  be  placed  at  either 
end  for  the  patient's  head  or  feet.     Beneath  the  table  should  be 


74  MANUAL  OF  SURGEEY 

spread  a  sheet  of  mackintosh  or  oilcloth,  or  a  number  of  papers,  for 
the  protection  of  the  floor,  and  alongside  of  the  table  should  be  placed 
the  bucket  or  slop  jar.  The  dining-table  may  be  used  for  instru- 
ments, sutures,  and  sponges;  the  bureau  for  extra  supplies,  splints, 
etc.;  the  wash-stand  with  the  two  basins  for  scrubbing  the  hands. 
The  etherizer  sits  on  one  chair  and  uses  a  second  for  his  hypoder- 
matic syringe  and  other  necessities;  on  the  third  chair  is  placed 
a  basin  containing  sterile  water  for  the  assistant;  the  fourth  chair  is 
used  by  the  operator  to  sit  upon  in  perineal  cases,  or  when  inverted, 
to  put  under  the  patient,  if  the  Trendelenburg  position  is  found 
necessary.  Previous  to  operation,  two  wash-boilers,  half  or  three- 
quarters  full  of  water,  should  be  provided;  in  one  is  placed  a  pitcher, 
three  basins,  and  a  sheet.  The  water  in  each  is  boiled  for  a  half  hour, 
and  that  in  the  boiler  containing  the  pitcher,  etc.,  allowed  to  cool 
without  removing  the  lid.  The  water  in  the  second  wash-boiler  is 
kept  hot.  The  water  from  a  kitchen  boiler  is  sterile,  and  may 
be  used,  providing  the  pipes  are  first  thoroughly  flushed.  The 
instruments  may  be  taken  to  the  house  in  a  copper  sterilizer,  and, 
after  boiling,  both  the  sterilizer  and  its  lid  may  be  used  as  trays  for 
the  instruments  and  sutures.  The  operating  table  is  covered  with  a 
blanket  and  a  sheet,  and  over  this  is  put  a  Kelly  pad  or  a  piece  of 
rubber  sheeting,  which  drains  into  the  bucket  or  slop  jar.  While  the 
surgeon  is  sterilizing  his  hands,  the  patient  is  anesthetized  in  an 
adjoining  room.  After  the  hands  have  been  sterilized,  a  sterile 
gown  is  put  on,  and  the  sheet  is  removed  from  the  boiler,  wrung  out, 
and  spread  over  the  dining-table;  on  this  is  placed  the  sterilizer  and 
the  two  basins  from  the  boiler,  in  one  of  which  is  put  sterile  water, 
and  in  the  other  bichlorid  of  mercury  solution.  The  instruments, 
sutures,  sponges,  and  dressings  are  arranged  on  the  dining-table  in 
the  order  in  which  they  will  be  needed.  The  patient  is  carried  into 
the  room  by  the  etherizer  and  a  member  of  the  family,  so  that 
neither  the  surgeon  nor  his  assistant  will  soil  the  hands.  The  assist- 
ant sterilizes  his  hands  with  the  surgeon,  puts  on  a  sterile  gown, 
scrubs  the  patient,  and  redisinfects  his  hands  while  the  surgeon 
applies  the  alcohol  and  bichlorid  of  mercury.  A  towel  should  be 
soaking  in  the  bichlorid  of  mercury  solution,  so  that  if,  in  an  emer- 
gency, it  is  necessary  to  handle  some  unsterilized  object,  the  towel 
may  be  used  and  the  hand  saved.  It  is  better  to  have  caps,  gowns, 
sheets,  towels,  and  dressings  sterilized  at  the  surgeon's  ofhce  or 
hospital  and  sent  to  the  patient's  house,  as  boiling  them  at  the  house 
previous  to  operation  necessitates  the  use  of  wet  materials.  One  of 
the  great  inconveniences  in  operating  in  a  private  house  is  the  for- 


SURGICAL  TECHNIC  75 

getting  of  some  instrument  that  is  needed,  or  the  wanting  of  some 
instrument  or  apphance  to  meet  an  unexpected  condition  which  has 
arisen.  For  this  reason  it  is  a  good  plan  to  have  a  list  of  the  different 
instruments,  etc.,  which  may  be  needed  in  various  operations,  to 
check  these  off  as  they  are  packed  into  the  hand-bag,  and  to  be 
prepared  for  any  possible  emergency  The  following  articles  may 
be  needed  in  any  operation:  Anesthetic,  mouth-gag,  tongue-forceps, 
hypodermatic  syringe,  strychnin,  atropin,  adrenaHn,  tracheotomy 
tube,  razor,  soap,  nail-brush,  lubrichondrin  or  other  sterile  lubricant, 
alcohol,  catheter,  carbolic  acid,  bichlorid  of  mercury  tablets,  glass 
syringe,  caps  (towels  or  gauze  may  be  used  for  this  purpose) ,  gowns 
(sterile  sheets  will  do  in  an  emergency),  gloves,  dressings,  sponges, 
bandages,  sterilized  towels  and  sheets,  adhesive  plaster,  two  scalpels, 
tissue  forceps,  hemostatic  forceps,  probe,  two  pairs  of  scissors, 
needles,  needle  holder,  aneurysm  needle,  retractors,  curette,  drainage 
tubes,  silk,  catgut,  silkworm  gut,  safety  pins,  Kelly  pad,  instrument 
sterilizer,  and  an  infusion  apparatus.  Special  instruments  that  may 
be  needed  in  various  operations  are  mentioned  in  connection  with  the 
operation  in  subsequent  pages.  The  after  care  of  a  patient  in  a 
private  house  differs  in  no  way  from  that  in  a  hospital.  It  is  essen- 
tial that,  in  an  emergency,  the  nurse  or  caretaker  have  some  means  of 
immediately  communicating  with  the  surgeon;  there  should  be  a 
telephone  in  the  house,  or  the  nurse  should  know  w^here  th-e  nearest 
one  is  situated.  The  bed  room  should  have  been  thoroughly  cleansed 
previous  to  operation,  and  the  follow^ing  articles  should  be  handy: 
Pillows,  blankets,  sheets,  mackintosh  spread,  hot  water  bottles  or 
bags,  towels,  dressings,  bandages,  bed-pan,  urinal,  feeding-cup, 
medicine  measure,  temperature  chart  and  note  book,  carbolic  acid  or 
bichlorid  of  mercury,  ice,  enema  syringe,  catheter,  hypodermatic 
syringe,  strychnin,  atropin,  and  morphin. 


CHAPTER  V 
BANDAGES 

Bandages  are  employed  to  hold  dressings  or  splints  in  place,  to 
exert  pressure,  and  to  mantain  parts  in  position  after  the  correction 
of  deformity. 

Various  kinds  of  material  may  be  employed.  Muslin  is  strong 
and  cheap.  Flannel  is  soft  and  elastic  and  adapts  itself  uniformly  to 
uneven  surfaces;  it  is  used  principally  for  eye  and  abdominal 
bandages,  and  as  a  primary  roller  beneath  plaster-of-Paris.  Gauze  is 
light,  and  readily  adaptable  to  the  various  parts;  it  is  applied  without 
making  reverses,  and  is  less  liable  to  displacement  than  musHn. 
Rubber  is  used  when  hrm  pressure  is  desired.  Plaster-of-Paris, 
silicate  of  soda,  starch,  etc.,  are  used  when  absolute  immobility  is 
demanded. 

The  roller  bandage  has  a  body,  an  initial  and  a  terminal  extremity 
an  inner  and  outer  surface,  and  an  upper  and  lower  edge.  In  pre- 
paring a.mushn  roller  bandage  the  material  is  torn  into  strips,  the 
selvage  removed,  and  one  end  folded  repeatedly  until  a  small  cylinder 
is  formed.  This  is  held  between  the  thumb  and  index  finger  of  one 
hand,  with  the  body  underneath,  while  the  free  extremity  passes 
between  the  thumb  and  index  linger  of  the  other  hand,  with  the 
thumb  above.  By  pronating  and  supinating  both  hands  and  making 
tension,  the  free  portion  of  the  bandage  is  wound  tightly  and  evenly; 
a  loosely  rolled  bandage  is  not  easily  applied.  By  the  use  of  a 
machine,  bandages  can  be  rolled  better  and  more  quickly.  After 
winding,  the  remaining  selvage  is  removed  and  the  end  folded  under 
and  pinned. 

A  part  is  bandaged  in  the  position  in  which  it  is  to  be  retained;  a 
bandage  appHed  to  a  limb  in  extension  will  be  too  tight  when  the  limb 
is  flexed,  one  apphed  in  flexion  will  become  loose  during  extension. 
It  should  be  applied  neatly  and  with  uniform  firmness;  if  too  tight, 
it  will  cause  pain,  perhaps  inflammation,  or  even  gangrene;  if  too 
loose,  the  dressing  will  soon  become  displaced.  Bony  prominences 
and  tender  points  should  be  padded,  and  apposed  skin  surfaces 
separated  by  Hnt  or  cotton.  To  begin  a  bandage,  apply  the  outer 
surface  of  the  initial  extremity  to  the  part  at  its  smallest  diameter, 

76 


BANDAGES 


77 


and  hold  it  with  the  left  hand  until  fixed  by  a  few  turns  of  the  roller. 
The  terminal  end  is  secured  by  pinning  it  in  such  a  way  that  the  point 
will  be  concealed,  and  will  not  enter  the  tissues  when  the  part  is 
moved,  by  splitting  the  bandage  and  tying  the  two  ends  around  the 
part,  or  by  encircling  the  part  with  a  strip  of  adhesive  plaster.  A 
bandage  is  removed  by  cutting  with  blunt  pointed  scissors,  or  by 
gathering  the  folds  in  a  loose  mass  as  it  is  unwound. 

Varieties  of  Bandages.- — The  circular  bandage  (Fig.  i8)  is  applied 
transversely  to  cylindric  parts.  The  oblique,  or  rapid  spiral,  is 
applied  in  ascending  turns,  between  which  there  are  uncovered  spaces. 
The  spiral  bandage  may  be  ascending  or  descending  each  successive 
turn  overlapping  a  portion  of  the  preceding  one.  The  spiral  reversed 
bandage  (Fig.  19)  is  used  on  parts  which  are  conical  in  shape.  After 
fixing  the  initial  extremity,  the  body  is  carried  oft'  oblique  y  for  four  or 


Fig.   18. —  I.   Circular       Fig.    19. — Spiral  reversed     Fig.  20.— Figure  of  8  of  knee, 
turns.    2.  Oblique  turns.  of  the  forearm. 

3.   Spiral  turns. 

five  inches ,  the  applied  turn  held  by  the  thumb  of  the  left  hand ,  the  por- 
tion of  bandage  between  the  hands  slackened,  the  right  hand  hold- 
ing the  body  of  the  bandage  changed  from  extreme  supination  to 
pronation,  and  the  bandage  passed  around  the  limb  and  drawn 
firm .  The  reverses  should  be  in  line,  and  should  not  be  made  over  bony 
prominences,  lest  they  cause  discomfort.  The  figure  of  8  bandage 
(Fig.  20)  consists  of  two  loops  of  bandage  forming  a  figure  of  8,  and 
is  used  to  cover  projecting  parts,  such  as  the  elbow  and  knee  in 
flexion.  When  a  number  of  turns  are  made,  each  one  higher  than  the 
preceding  one,  they  form  what  is  called  a  spica  bandage  (Fig.  48). 
The  recurrent  bandage  (Fig.  23)  is  used  for  amputation  stumps, 
the  top  of  the  head,  or  the  end  of  a  finger.  It  is  applied  by  fixing 
the  initial  extremity  by  circular  turns,  making  reverses  over  the  end 
of  the  part  until  it  is  covered,  and  then  terminating  by  a  few  spiral 
or  spiral  reversed  turns. 


78  MANUAL  OF  SURGERY 

Tailed  bandages  are  made  from  strips  of  muslin,  which  vary  in 
length  and  width  according  to  the  part  to  be  covered.  Each  end  is 
torn  into  two  or  more  pieces  up  to  within  a  few  inches  of  the  center. 

Handkerchief  bandages  are  made  of  handkerchiefs  or  other 
pliable  material,  and  are  especially  useful  in  emergency  cases.  A 
handkerchief  folded  squarely  across  the  middle  forms  a  rectangle, 
diagonally  a  triangle,  and  when  rolled  loosely  it  forms  a  cravat. 

BANDAGES  OF  THE  HEAD 

Barton's  Bandage  (Fig.  21). — 6  yards  x  2  inches.  Place  the 
initial  extremity  of  the  bandage  just  beneath  the  occipital  protuber- 
ance, carry  the  roller  obliquely  upward  under  the  right  parietal 
eminence,  across  the  vertex,  downward  over  the  left  zygomatic 
arch,  under  the  chin,  upward  over  the  right  zygomatic  arch,  over  the 
top  of  the  head,  crossing  the  first  turn  in  the  median  line,  downward 


Fig.   21. — Barton's  bandage.  Fig.   22. — Gibson's  bandage. 

and  backward  under  the  left  parietal  eminence  to  the  starting  point, 
forward  under  the  right  ear,  around  the  front  of  the  chin,  and 
back  again  to  the  starting  point.  Three  complete  turns,  each 
exactly  covering  the  other,  are  thus  made,  and  a  pin  inserted  at  each 
crossing  point.  The  bandage  is  employed  in  fractures  and  disloca- 
tions to  fix  the  lower  jaw.  Great  care  must  be  exercised  in  the 
application  of  any  bandage  to  the  jaw  or  neck,  especially  in  uncon- 
scious patients,  as  it  may  interfere  with  respiration  or  the  escape  of 
vomited  material. 

Gibson's  Bandage  (Fig.  22).— 6  yards  x  2  inches.  Place  the 
initial  extremity  upon  the  vertex,  pass  downward  in  front  of  the 
left  ear,  under  the  chin,  and  up  in  front  of  the  right  ear  to  the  point 
of  starting.  Repeat  this  turn  twice.  On  arriving  at  the  right 
temple  for  the  third  time,  reverse  the  bandage  and  carry  it  horizon- 
tally around  the  head  from  forehead  to  occiput.  On  arriving  above 
the  left  ear  for  the  third  time,  drop  the  bandage  downward  and  carry 
it  around  the  nape  of  the  neck,  under  the  right  ear,  around  the 


BANDAGES  79 

front  of  the  chin,  and  ])ack  beneath  the  left  ear  to  the  nape  of  the 
neck.  Repeat  this  turn  twice,  and  then,  after  pinnin<^  the  Ijandage, 
make  a  reverse  over  the  top  of  the  head  in  the  median  hne.  Insert 
a  pin  at  each  crossing  point.  This  bandage  is  used  for  the  same 
purposes  as,  but  is  less  secure  than,  the  Barton  bandage. 

Oblique  of  the  Jaw.—  6  yards  x  2  inches.  If  the  left  jaw  is  to  be 
bandaged,  place  the  initial  extremity  above  and  in  front  of  the  right 
ear,  and  pass  around  the  forehead  from  your  left  to  right,  applying 
two  horizontal  turns  from  forehead  to  occiput;  on  arriving  above 
the  left  ear,  pass  down  obliquely  across  the  back  of  the  neck,  forward 
under  the  right  ear,  under  the  chin,  up  over  the  left  side  of  the  face 
at  the  edge  of  the  orbit,  obliquely  over  the  vertex,  down  behind  the 
right  ear,  under  the  chin,  and  up  over  the  affected  side,  where  each 
turn  overlaps  the  preceding  one  from  the  orbit  to  the  ear.  Behind 
the  right  ear  the  turns  overlie  each  other.  On  arriving  above  the 
right  ear  with  the  last  turn,  the  bandage  is  reversed  and  terminated 
as  it  was  begun  by  encircling  the  head  from  fore- 
head to  occipuK  If  the  right  jaw  is  to  be  bandaged, 
substitute  right  for  left,  and  left  for  right,  in  the 
above  description.  This  bandage  is  used  for  the 
retention  of  dressings  to  the  parotid  region  and 
angle  of  the  jaw. 

Recurrent  of  the  Head  (Fig.  23). — 6  yards  x  2 
inches.  Beginning  at  the  right  temple  two  horizon- 
tal turns  are  applied;  from  the  center  of  the  fore-  Recurrent  of  head. 
head,  where  the  bandage  is  pinned  or  held  by  an 
assistant,  it  is  reversed  over  the  head  in  the  median  line  to  the  occi- 
put, where  it  is  held,  and  brought  back  to  the  forehead  covering 
one-half  of  the  median  turn.  It  is  then  carried  back  and  forth 
from  the  center  of  the  forehead  to  that  of  the  occiput,  alternately 
on  each  side  of  the  median  line,  each  turn  covering  two-thirds  of 
the  preceding  turn.  The  bandage  is  completed  by  two  horizontal 
turns.  It  may  be  made  more  secure  by  a  turn  passing  under  the 
chin,  or  by  a  cap  with  bands  fastened  under  the  chin.  Instead 
of  longitudinally,  the  recurrent  turns  may  be  applied  transversely. 

Crossed  Bandages  of  One  Eye. — 5  yards  x  2  inches.  To 
bandage  the  left  eye  begin  at  the  left  temple,  and  fix  by  two  horizon- 
tal turns  from  forehead  to  occiput,  from  the  patient's  left  to  right. 
On  arriving  for  the  second  time  above  the  right  ear,  pass  down 
under  the  occiput,  under  the  left  ear,  up  obliquely  over  the  left 
cheek,  over  the  left  eye,  and  up  over  the  side  of  the  head.  A  second 
or  perhaps  a  third  turn  is  applied,  over  lapping  the  preceding  one  one- 


8o  MANUAL  OF  SURGERY 

half  from  below  upwards  on  the  cheek  and  from  above  downwards 
on  the  head.  These  obHque  turns  may  be  alternated  with  horizontal 
occipito-frontal  turns,  by  which  the  bandage  is  terminated.  It  is 
more  comfortable  to  the  patient  to  have  the  ear  on  the  affected  side 
covered  w4th  cotton  and  included  in  the  bandage.  To  bandage  the 
right  eye  begin  at  the  same  point,  and  carry  the  bandage  from  the 
operator's  left  to  right. 


Fig.  24. — Crossed    bandage     Fig. 
of  both  eyes.     (Gould.) 


25. — Borsch' 
bandage. 


eye 


Fig.  26. — Oblique  ban- 
dage of  head,  to  be  com- 
pleted  by  a  circular  turn. 


The  crossed  bandage  of  both  eyes  (Fig.  24)  is  practically  a 
figure  of  8  bandage  with  circular  turns  around  the  head. 

Borsch's  eye  bandage  is  shown  in  Fig.  25. 

The  occipital  frontal  bandage  consists  of  figure  of  8  turns  applied 
to  the  head  longitudinally. 

The  oblique  bandage  of  the  head  (Fig.  26)  consists  of  figure  of  8 
turns  applied  transversely. 


Fig.  27. — Knotted  bandage 
of  temple. 


Fig.  28. — Four  tailed 
bandage  of  head. 


The  head  and  neck  bandage  also  is  a  figure  of  8  bandage.  The 
bandage  is  fixed  by  turns  around  the  head  above  the  ears,  then  carried 
across  the  back  of  the  neck,  around  the  throat,  and  back  to  the 
starting  point. 

The  knotted  bandage  of  the  temple,  used  for  hemorrhage,  is 
shown  in  Fig.  27,  a  double  roller  being  employed. 

Thefourtailed  bandage  is  shown  in  Fig.  28.  It  may  be  applied  to 
the  forehead  bv  tving  the  ends  under  the  chin  and  behind  the  head;  to 


BANDAGES  8 I 

the  occiput  b}-  tying  the  ends  around  the  forehead  and  under  the  chin ; 
or  to  the  chin  by  tying  the  ends  over  the  vertex  and  behind  the  neck. 

The  occipito -frontal  triangle  is  a  handkerchief  bandage  which  is 
appHed  by  placing  the  base  of  the  triangle  on  the  nape  of  the  neck 
bringing  the  apex  forward  over  the  forehead.  The  ends  of  the  base  are 
knotted  over  the  apex,  which  is  turned  up  over  the  knot  and  pinned. 

In  the  vertico-mental  triangle  the  base  of  the  triangle  is  placed  on 
the  top  of  the  head  with  the  apex  l)ackward;  the  two  ends  of  the 
base  are  knotted  under  the  chin  and  the  apex  pinned  at  one  side  of 
the  head. 

The  cravat  may  be  used  for  various  parts  of  the  head  when 
applied  in  the  form  of  a  figure  of  8. 


Square  cap  of  head. 


Fig.  30. —  Square  cap  of  head. 


The  square  cap  of  the  head  is  illustrated  in  Figs.  29  and  30.     The 

handkerchief  is  folded  in  the  form  of  a  rectangle,  with  one  of  the  free 
edges  projecting  an  inch  or  more  beyond  the  other.  The  outer 
corners  are  tied  under  the  chain;  the  inner  corners  are  drawn  out, 
carried  backwards,  and  knotted  behind  the  head. 


BANDAGES  OF  THE  UPPER  EXTREMITY 

The  spiral  of  the  finger  (Fig.  31) — ii^  yards  x  i  inch — is 
applied  by  placing  the  initial  extremity  lengthwise  on  the  finger, 
making  one  or  two  reverse  turns  over  the  end  of  the  finger,  then 
reversing  and  covering  the  finger  by  ascending  spiral  turns. 

The  Spica  of  the  Thumb.— 3  yards  x  i  inch.  Fix  the  initial 
extremity  by  two  circular  turns  around  the  wrist,  and  carry  the 
bandage  to  the  tip  of  the  thumb,  which  is  encircled  once.  Figure  of 
8  turns  around  the  thumb  and  wrist,  each  one  overlapping  the  pre- 
vious one  and  alternating  with  a  circular  turn  around  the  wrist, 
are  now  applied  until  the  thumb  is  covered.  The  bandage  is  termi- 
nated bv  a  circular  turn  around  the  wrist. 


82 


MANUAL  OF  SURGERY 


Gauntlet  Bandage  (Fig.  32).- — 3  yards  x  i  inch.  Fix  the  initial 
extremity  around  the  wrist,  and  pass  across  the  palm  to  the  base  of 
the  thumb  if  bandaging  the  left  hand;  pass  by  an  oblique  turn  to  the 
tip  of  the  thumb,  which  is  encircled  leaving  the  tip  uncovered;  cover 
the  thumb  by  ascending  spiral  or  spiral  reversed  turns,  then  pass 
across  the  dorsum  of  the  hand  to  the  ulnar  side  of  the  wrist  and  en- 
circle once.  The  index  finger  is  bandaged  next,  and  so  the  other 
fingers,  the  bandage  being  terminated  by  a  turn  around  the  wrist. 

Demigauntlet  Bandage  (Fig.  33).^ — Fix  the  initial  extremity 
around  the  wrist.  If  bandaging  the  dorsum  of  the  left  hand,  pass  to 
the  base  of  the  little  finger,  encircle  it,  then  pass  to  the  radial  side  of 
the  wrist  and  encircle  it.  The  bandage  is  then  carried  to  the  base 
of  the  ring  finger,  and  in  turn  to  all  the  others,  alternating  a  turn 
around  the  finger  with  one  around  the  wrist. 


Fig.   31. --Spiral  of 
finger.      (Gould.) 


Fig.  32. — Gauntlet. 
(Gould.) 


Fig.   33. — Demigauntlet. 
(Gould.) 


Spiral  Reversed  of  the  Upper  Extremity  (Fig.  19)  .^7  yards  x  2^2 
inches.  P^ix  the  initial  extremity  by  circular  turns  around  the  wrist. 
Pass  obliquely  across  the  dorsum  of  the  hand  to  the  tips  of  the  lingers 
and  make  a  circular  turn.  The  fingers  are  covered  by  spiral  reversed 
turns,  the  back  of  the  hand  and  wrist  by  figure  of  8  turns,  the  forearm 
and  humerus  by  spiral  reversed  turns,  and  the  bandage  terminated 
as  a  spica  of  the  shoulder.  If  the  elbow  is  to  be  dressed  in  flexion, 
figure  of  8  turns  are  used  in  this  region.  A  bandage  may  be  applied 
also  to  the  upper  extremity  in  a  series  of  figure  of  8  turns.  This  is 
more  secure  than  the  spiral  reversed. 

Spica  of  the  Shoulder  (Fig.  34) .^8  yards  x  2}^  inches.  FLx 
the  initial  extremity  by  circular  turns  around  the  humerus  on  a 
level  with  the  axillary  fold.  If  bandaging  the  right  shoulder,  carry 
the  bandage  across  the  front  of  the  chest,  through  the  left  axilla, 
and  across  the  back  to  the  arm.  Encircle  the  arm  and  chest  al- 
ternately, making  each  successive  turn  ascend  higher  than  the  pre- 


BANDAGES 


83 


vious  one,  by  exposing  one-half  or  two-thirds  its  width,  until  the 
shoulder  is  completely  covered.  .1  descending  spica  is  applied  by 
fixing  the  bandage  as  described,  and  placing  the  first  turn  high  up 
over  the  shoulder  and  overlapping  from  above  downwards. 


Fig.  34. — Spica  of  shoulder. 
(Gould.) 


Fig.  35. — Brachio-cervical  triangle. 
(Esmarch  and  Kowalzig.) 


Fig.   36. — Oblique  triangle  of  arm  and  chest.      (Davis.) 


Fig.  37. — Oblique  triangle  of  arm  FiG.  38. — Triangle  for  suspending 

and  chest,  second  method.    (Esmarch       arm  from  injured   side.     (Esmarch 
and  Kowalzig.)  .    and  Kowalzig.) 

The  figure  of  8  of  the  neck  and  axilla  is  applied  by  encircling  the 
neck,  then  passing  under  the  axilla,  and  ascending  to  the  starting 
point,  the  turns  intersecting  over  the  shoulder. 

A  few  of  the  handkerchief  bandages  and  sh'ngs  for  the  upper  ex- 
tremity are  shown  in  Figs.  35  to  38. 


84 


MANUAL  OF  SURGERY 


BANDAGES  OF  THE  TRUNK 

The  spiral  bandage  of  the  chest  consists  of  overlapping  spiral 
turns,  ascending  from  the  waist  to  the  level  of  the  axillae.  The  final 
spiral  turn  is  pinned  at  the  spine  and  the  bandage  carried  over  one 
shoulder  to  the  middle  of  the  sternum  where  it  is  again  pinned.  It 
is  then  brought  back  across  the  opposite  shoulder  to  the  spine,  thus 
acting  like  suspenders. 

The  figure  of  8  of  the  shoulders^ — 6  yards  x  2Y1  inches^ — may  be 
applied  anteriorly  (Fig.  39)  or  posteriorly.  • 

Suspensory  Bandage  of  the  Breast  (Fig.  40). — 7  yards  x  23^^ 
inches.  Place  the  initial  extremity  on  the  scapula  of  the  afifected 
side,  and  pass  over  the  opposite  shoulder,  down  obliquely  under  the 
affected  breast,  and  beneath  the  axilla  to  the  starting  point.  Con- 
tinue around  the  chest  under  the  sound  breast,  and  across  the  lower 
portion  of  the  affected  one.     These  turns  are  alternately  continued, 


Fig.  39. — Anterior  figure  of  8  of 
shoulders.     (Gould.) 


Fig.  40.- 


-Suspensory  of  breast. 
(Gould.) 


each  one  overlapping  from  below  upwards,  until  the  breast  is  covered. 
To  dress  both  breasts  apply  an  oblique  turn  to  one  side,  then  a  circular 
turn,  then  an  oblique  turn  to  the  opposite  side. 

Velpeau's  Bandage  for  Fractured  Clavicle  (Fig.  41).— 7  yards  x 
2)2  inches.  First  place  the  arm  in  the  Velpeau  position,  the  hand 
of  the  injured  side  on  the  opposite  shoulder.  From  the  axilla  of  the 
sound  side  pass  across  the  back,  over  the  outer  part  of  the  injured 
shoulder,  down  across  the  middle  of  the  arm,  behind  the  elbow,  across 
the  chest,  and  through  the  axilla  of  the  sound  side  to  the  point  of 
starting.  Next  apply  a  horizontal  turn  on  a  level  with  the  affected 
elbow.  Repeat  these  turns  until  the  elbow  is  covered  with  the  verti- 
cal, and  the  wrist  with  the  horizontal  turns.  The  vertical  turns 
should  overlap  two-thirds  of  each  preceding  turn,  and  the  horizontal 
ones,  one-third.     Secure  the  bandage  by  strips  of  adhesive  plaster. 

Desault's  Bandage  for  Fractured  Clavicle  (Fig.  42).^ — Three 
bandages,  7  yards  x  2  '  2  inches,  and  a  wedge-shaped  pad.  The  pad  is 
placed  in  the  axilla  of  the  injured  side,  base  up.     The  arm  is  allowed 


BANDAGES 


to  hang  by  the  side,  and  the  forearm  is  flexed  at  a  right  angle.  The 
first  bandage  is  used  to  liold  the  pad  in  place.  Beginning  at  the  base 
of  the  pad,  descending  spiral  turns,  encircling  the  chest,  are  applied 
down  to  its  apex  near  the  elbow,  and  then  ascending  spiral  turns 
back  to  its  base.  To  hold  the  pad  up  in  the  axilla,  the  first  bandage 
may  be  terminated  with  a  figure  of  8  turn  of  the  opposite  shoulder. 
The  second  bandage  binds  the  arm  to  the  side.  Beginning  at  the 
axilla  of  the  sound  side,  on  a  level  with  the  base  of  the  pad,  descending 
spiral  turns  are  applied,  with  increasing  firmness,  down  to  the  elbow 
so  as  to  carry  the  shoulder  outwards.  The  third  bandage  is  applied 
in  the  form  of  an  anterior  and  a  posterior  triangle,  the  apex  of  each 
being  formed  by  the  axilla  of  the  sound  side,  and  the  base  by  the 
humerus  of  the  injured  side.  Begin  the  bandage  at  the  axilla  of  the 
sound  side  posteriorly,  pass  over  the  affected  shoulder,  down  in  front 
of  and  parallel  with  the  humerus,  under  the  elbow,  and  across  the 


Fig.  41. — Velpeau  bandage.       Fig.  42. — Desault  bandage.     Fig.  43. — Many  tailed 
(Gould.)  (Gould.)  bandage  of  abdomen. 

back  to  the  starting  point.  The  anterior  triangle  is  applied  in  the 
same  way,  by  continuing  the  bandage  through  the  axilla,  across  the 
chest,  over  the  shoulder  of  the  injured  side,  down  behind  the  humerus, 
under  the  elbow,  and  back  across  the  front  of  the  chest  to  the  starting 
point.  The  formula  of  both  triangles  is,  from  axilla,  to  shoulder,  to 
elbow,  and  back  to  axilla.  These  turns  are  repeated  two  or  three 
times,  each  succeeding  turn  covering  in  two-thirds  of  the  preceding 
one.  The  third  bandage  carries  the  injured  shoulder  upwards  and 
backwards. 

The  double  T  bandage  of  the  chest  consists  of  a  broad  band  w^hich 
encircles  the  chest,  and  to  which  are  attached  two  narrow  bands,  one 
passing  over  each  shoulder. 

The  double  T  bandage  of  the  abdomen  is  similar  to  the  above. 
The  vertical  strips  are  attached  to  the  lower  edge,  and  are  passed 
from  behind  forward  between  the  thighs  and  pinned  in  front,  to 
prevent  the  binder  from  slipping  up  on  the  abdomen. 


86  MANUAL  OF  SURGERY 

The  many  tailed  or  Scultetus  bandage  of  the  abdomen  (Fig.  43) 

consists  of  a  piece  of  flannel  long  enough  to  reach  one  and  a  half 
times  around  the  body  and  wide  enough  to  reach  from  the  costal 
border  to  the  pubic  bone.  Each  end  is  torn,  for  one-third  the  length 
of  the  bandage,  into  several  tails.  The  untorn  portion  is  placed 
behind,  and  the  tails  are  overlapped  alternately  in  front,  from 
above  downwards,  and  secured  by  safety  pins. 

The  T  bandage  of  the  perineum  consists  of  a  strip  of  muslin 
about  23^^  inches  wide,  and  long  enough  to  'fasten  around  the  ab- 
domen. To  the  center  of  this  is  attached  a  strip  about  five  inches 
wide  and  about  two  feet  long,  which  passes  between  the  thighs  and 
is  fastened  in  front,  either  by  pinning  it  to  the  horizontal  band,  or  by 


Fig.  44. — Triangle  for  suspending  breast.      (Davis.) 

tearing  it  into  two  bfinds  (in  the  male)  and  knotting  each  to  the 
horizontal  band. 

The  handkerchief  bandage  for  suspending  the  breast  is  illus- 
trated in  Fig.  44. 

BANDAGES  OF  THE  LOWER  EXTREMITY 

Foot  Bandage  Covering  the  Heel  (American). — 6  yards  x  2 
inches.  Fix  the  initial  extremity  at  the  ankle  by  two  circular  turns, 
pass  obliquely  across  the  dorsum  of  the  foot  to  the  base  of  the  toes, 
and  apply  a  complete  circular  turn.  Ascend  over  the  dorsum  by  several 
spiral  reversed  turns  until  opposite  the  heel,  around  which  the  band- 
age is  carried  by  a  circular  turn;  next  pass  above  the  heel,  beneath 
the  arch  of  the  foot,  then  up  over  the  instep  (Fig.  45).  Similar 
turns  are  applied  to  cover  the  other  side  of  the  heel,  and  the  bandage 
terminated  by  encircling  the  ankle. 

The  foot  bandage  not  covering  the  heel  (French)  is  the  same  as 
the  above,  except  that  the  ankle  is  covered  by  figure  of  8  turns  and 
the  heel  remains  exposed. 

The  spica  bandage  of  the  foot  is  explained  by  Fig.  46. 


BANDAGES 


87 


The  spiral  reversed  of  the  lower  extremity  is  similar  to  that  of  the 
upper  extremity. 

The  figure  of  8  of  the  leg  is  shown  in  Fig.  47. 

Spica  Bandage  of  One  Groin  (Fig.  48).— 7  yards  x  21^2  inches. 
Fix  the  initial  extremity  at  the  upper  portion  of  the  right  thigh  near 


Fig.   45. — American  bandage  of  heel;  circular' 
turns  about  ankle  have  been  omitted. 


Fig.   46. — Spica  of  foot. 


the  perineum,  by  two  circular  turns;  pass  obliquely  across  the  front 
of  the  pelvis,  just  above  the  pubes,  to  the  top  of  the  left  thigh,  across 
the  back,  obliquely  down  across  the  first  tarn  at  the  junction  of  the 
thigh  with  the  scrotum,  and  then  around  the  thigh.  These  turns 
are  repeated,  overlapping  from  below  upwards  {ascending  spica). 


Pig.  47. — Figure  of  8  of  leg.      (Davis.) 


Fig.  48. — Spica  of  groin. 


The  bandage  may  be  applied  also  by  encircling  the  pelvis  higher  up 
and  overlapping  from  above  downwards  {descending  spica) . 

Spica  of  Both  Groins. — 12  yards  x  23^^  inches.  Fix  the  initial 
extremity  as  in  the  single  spica,  and  pass  obHquely  across  the  front 
of  the  pelvis  to  the  opposite  side  01  the  abdomen,  across  the  back,  and 
obliquely  downward  to  the  outer  side  of  the  left  thigh.     Apply  a 


88 


MANUAL  OF  SURGERY 


circular  turn  to  the  left  thigh,  and  from  the  inner  side  of  the  thigh 
pass  obhquely  upward  and  outward  over  the  same  hip;  then  apply 
a  circular  turn  around  the  waist,  pass  across  the  back  again,  and 


Pig.  49. — Sacro-pubic  triangle. 
(Esmarch  and  Kowalzig.) 


Fig. 


50. — Scrotal  triangle. 
(Davis.) 


down  in  front  of  the  right  thigh;  carry  the  bandage  around  the  thigh, 
and  from  the  outer  side  of  the  thigh  repeat  the  turns,  overlapping 
from  below  upwards,  and  terminating  by  a  circular  turn  around  the 


--^W 


Triangulc 
of  knee. 


Tibial 
triangle. 


Fk;.  52. —  Malleolo-phalan- 
geal  triangle.  (Esmarch  and 
Kowalzig.) 


Tibial 
cravat. 


Tarso- 
malleolar 
cravat. 


Fig.  si.  — Handkerchief 
bandages  of  lower  extremity. 
(Davis.) 


Fig.  53. — Gerdy's  extension 
cravat.      (Davis.) 


abdomen  or  thigh.     A  spica  bandage  may  be  applied  to  the  outer 
aspect  of  the  thigh  or  to  the  buttock  in  the  same  way. 

Figures  49  to  53  demonstrate  the  use  of  the  handkerchief  band- 
ages of  the  lower  extremity. 


BANDAGES  89 

Fixed  dressings  arc  largely  used  to  immobilize  parts  after  frac- 
tures, osteotomy,  and  tenotomy,  and  in  the  treatment  of  inflamma- 
tory affections  of  joints  and  deformities.  Among  the  materials 
which  have  been  used  for  this  purpose  are  glue,  gum  arable,  paiaffin, 
and  tripolith,  but  those  most  commonly  employed  are  plaster-of- 
Paris,  silicate  of  soda,  and  starch. 

Plaster-of-Paris  is  the  best  material  for  a  fixed  dressing.  Coarse 
cotton  or  crinolin  bandages  are  rolled  by  hand  or  machine,  the 
meshes  being  filled  with  dry  plaster.  Owing  to  the  hydroscopic 
powers  of  the  plaster-of-Paris,  the  bandages  should  be  kept  in  air 
tight  receptacles,  or  baked  before  use  in  order  to  drive  off  the  mois- 
ture. Bony  prominences  are  first  padded  and  a  flannel  bandage 
applied.  The  plaster-of-Paris  bandages  are  submerged  in  water 
until  the  bubbles  of  air  cease  to  escape,  and,  after  squeezing  out  the 
excess  of  water,  applied  evenly  to  the  limb  until  the  desired  thickness 
is  obtained,  making  as  few  reverses  as  possible.     The  appearance  of 


Fig.   54. — Stirrup  plaster-of-Paris  dressing  for  knee.      (Esmarch  and  Kowalzig.) 

the  cast  is  improved  by  coating  it  with  plaster-of-Paris  cream,  which 
is  prepared  by  mixing  equal  quantities  of  plaster-of-Paris  and  water. 
The  cast  may  be  strengthened  by  incorporating  in  it  strips  of  wood, 
metal,  cardboard,  etc.,  and  it  may  be  coated  with  a  layer  of  silicate 
of  soda  or  varnish,  to  render  it  impervious  to  water.  The  finest 
grade  of  plaster  hardens  in  fifteen  minutes,  the  coarser  grades  in  a 
longer  time.  The  hardening  process  may  be  hastened  by  using  hot 
water,  or  by  adding  salt  (one  ounce  to  the  quart  of  water),  alum,  or 
cement;  it  may  be  delayed  by  using  cold  water,  or  by  adding  starch, 
glue,  dextrine,  or  milk.  When  nearly  dry  the  cast  should  be  cut 
with  a  sharp  knife;  in  order  to  protect  the  patient,  a  narrow  strip  of 
sheet  lead  or  similar  material  may  be  placed  over  the  flannel  bandage 
before  the  plaster  is  applied.  The  hardened  plaster  may  be  cut 
with  a  knife,  saw,  or  shears,  after  the  line  of  division  has  been 
moistened  with  hydrochloric  acid,  vinegar,  hydrogen  peroxide,  or  salt 
water.  When  there  is  a  wound  which  will  require  dressing,  it  should 
be  surrounded  by  a  strip  of  lead  or  other  material  which  will  form  a 


90  MANUAL  OF  SURGERY 

projection  through  the  plaster  dressing  and  indicate  the  portion  to  be 
cut  away,  or  the  area  may  be  left  uncovered  when  the  plaster  is 
applied.  Another  method,  particularly  useful  after  resection  of 
joints,  is  to  apply  the  cast  in  two  sections,  which  are  connected  by 
metal  or  wooden  arches  (Fig.  54),  the  ends  of  which  are  horizontal  to 
permit  of  their  incorporation  in  the  plaster-of-Paris.  Plaster-of -Paris 
splints  may  be  made  by  spreading  plaster-of-Paris  cream  between 
layers  of  linen,  which  are  molded  to  the  parts  and  allowed  to  harden. 

Silicate  of  soda  can  be  bought  as  a  solution,  which  is  sometimes 
called  liquid  glass.  It  may  be  applied  in  the  same  way  as  plaster,  or 
a  few  layers  of  gauze  bandage  may  be  applied  and  painted  with  the 
solution,  this  process  being  continued  until  the  desired  thickness  is 
obtained.  The  silicate  cast  is  light  and  strong,  but  has  the  disadvan- 
tage of  drying  very  slowly  (twenty-four  hours) ;  the  process  may  be 
hastened  by  adding  pulverized  chalk  or  cement. 

The  starch  bandage  is  used  when  a  very  firm  splint  is  not  required. 
The  bandage  is  soaked  in  a  solution  of  starch,  made  with  boiling 
water,  and  applied  like  the  plaster  bandage.  It  also  requires  twenty- 
four  hours  or  more  to  harden.  , 


CHAPTER  VI 
INFLAMMATION 

Inflammation  consists  of  (i)  changes  in  the  blood  vessels,  (2)  the 
passage  of  fluids  and  solids  from  the  blood  vessels,  and  (3)  changes  in 
the  perivascular  tissues. 

The  predisposing  causes  of  inflammation  are  those  already  listed 
under  "Susceptibihty,"  Chapter  III.  The  exciting  causes  are  injury 
and  infection.  Injury  may  be  mechanical,  such  as  blows  and 
wounds;  chemical,  such  as  strong  acids  or  alkalies,  stings  of  insects, 
and  bites  of  animals;  or  thermal,  either  heat  or  cold;  all  of  which 
kill  the  tissue  cells,  the  resulting  products  of  the  dead  cells  acting 
as  irritants.  Infection  is  by  far  the  most  common  cause,  and  the 
most  important  factor  even  in  traumatic  inflammation.  Bacteria 
induce  inflammation  by  their  toxins,  which  act  directly,  and  also 
indirectly,  like  trauma,  by  killing  the  cells,  which  set  free  irritating 
products. 

1.  The  changes  in  the  blood  vessels  consist  of  a  momentary 
contraction,  followed  by  active  hyperemia,  i.e.,  a  dilatation  of  the 
blood  vessels  with  a  marked  acceleration  in  the  velocity  of  the  blood 
stream.  After  a  time  retardation  of  the  blood  current  occurs,  and 
the  stream  becomes  slower  and  slower  {passive  hyperemia},  until  in 
some  cases  it  no  longer  progresses,  but  sways  backward  and  forward 
(oscillation);  finally  all  motion  may  cease  (stasis),  and  the  blood  may 
coagulate  (thrombosis)  or  rupture  the  vessel  wall  (rhexis).  While 
these  changes  are  taking  place,  the  leukocytes  separate  from  the  axial 
stream  and  mass  themselves  along  the  walls  of  the  blood  vessels 
(margination) ,  while  the  red  corpuscles  run  together,  forming  rows,  or 
rouleaux.  The  blood  plaques  are  increased  in  number  and  tend 
to  associate  with  the  leukocytes  along  the  sides  of  the  stream. 

2.  The  passage  of  fluids  and  sohds  from  the  vessels,  or  exudation, 
begins  as  soon  as  the  blood  vessels  have  dilated.  The  exuded 
material  includes  liquor  sanguinis  or  plasma,  red  cells,  leukocytes, 
and  blood  plaques.  Normally  the  liquor  sanguinis  leaves  the  interior 
of  the  blood  vessels  to  nourish  the  tissue  cells,  and  the  excess  is 
absorbed  by  the  lymphatics,  but  in  inflammation  the  amount  is  much 
greater  than  that  which  can  be  removed  by  the  lymph  vessels.     The 

91 


92  MANUAL  OF  SURGERY 

process  is  probably  not  a  simple  filtration,  but  may  be  likened  to 
secretion,  in  that  the  endothelial  cells  play  an  active  part.  This  fluid 
dilutes  the  toxins,  contains  bactericidal  and  antitoxic  seia,  and  in 
chronic  inflammation  increases  the  nourishment  of  the  tissues.  The 
leukocytes,  particularly  the  polymorphonuclears,  migrate  from  the 
vessels  by  insinuating  a  little  process  between  the  endothelial  cells, 
which  have  been  weakened,  stretched,  and  probably  separated  as 
the  result  of  the  vascular  dilatation;  this  process,  or  pseudopodium, 
gradually  works  its  way  through  the  vessel  wall  until  it  reaches  the 
exterior,  when  the  body  of  the  leukocyte  flows  into  the  pseudopod 
and  is  then  in  the  perivascular  tissues.  Although  the  leukocytes 
migrate  to  some  extent  from  the  capillaries  and  arterioles,  the 
process  is  most  active  in  the  venules ;  migration  begins  with  the  onset 
of  hyperemia,  and  continues  as  long  as  the  blood  is  in  motion.  There 
is  a  vast  increase  in  the  number  of  leukocytes,  not  only  in  the  in- 
fl.ammatory  area,  but  also  in  the  general  blood  stream  (leukocytosis). 
The  red  cells  and  blood  plaques,  being  incapable  of  ameboid  move- 
ments, are  passively  carried  through  the  vessel  walls  with  the  plasma 
{diapedesis) . 

3.  Changes  in  the  Perivascular  Tissues. — As  the  result  of  the 
breaking  up  of  some  of  the  leukocytes,  which  sets  free  fibrin  ferment, 
the  plasma  coagulates,  forming  inflammatory  lymph;  the  serum  which 
forms  infiltrates  the  tissues,  giving  rise  to  edema.  The  leukocytes 
destroy  bacteria,  devour  particles  of  dead  tissue,  and  pass  back  into 
the  circulation  through  the  lymphatics;  if  suppuration  ensues  they 
form  pus  cells.  The  red  blood  cells  and  the  blood  plaques  are  dis- 
integrated, and  reabsorbed  by  the  lymphatics,  or  are  devoured  by  the 
leukocytes  and  fibroblasts.  The  connective  tissue  cells  proliferate, 
and  the  resulting  cells  are  known  as  fibroblasts.  It  is  believed  that 
the  leukocytes  neither  multiply,  nor  enter  into  the  formation  of  new 
tissue.  The  mass  formed  by  the  fibroblasts  is  called  embryonic  or 
indifferent  tissue,  because  it  repairs  any  of  the  various  tissues  in  which 
it  may  be  found. 

In  inflammation  of  non-vascular  tissue,  e.g.,  the  cornea  and 
cartilage,  the  surrounding  blood  vessels  dilate,  and  exude  their 
contents  into  the  lymph  or  intercellular  spaces  of  the  tissues,  where 
the  exudate  undergoes  the  changes  already  described. 

The  pathology  of  chronic  mflammaticn  is  practically  the  same  as 
that  of  the  acute  form,  except  that  the  phenomena  are  less  active  and 
much  longer  in  duration.  The  chief  difference  is  seen  in  the  be- 
havior of  the  perivascular  tissues,  which  in  chronic  inflammation 
become  thickened  and  hardened  as  the  result  of  the  proliferation  of 


INFLAMMATION  93 

the  fixed  connective  tissue  cells;  later,  particularly  in  syphilitic  and 
tuberculous  subjects,  marked  degenerative  changes  may  take  place 
in  this  tissue. 

Inflammation  extends  in  the  same  manner  as  other  infections 
(Chai).  111). 

Inflammation  terminates  in  recovery  or  in  death  of  the  tissues. 
Recovery  takes  place  suddenly  {delitescence) ;  gradually,  the  exudate 
being  absorbed  by  the  lymphatics  {resolution);  or  with  new  growth, 
e.g.,  in  the  formation  of  adhesions,  the  embryonic  tissue  becoming 
vascularized,  or  organized,  and  the  fibroblasts  forming  fibrous  tissue. 
Death  occurs  as  suppuration,  ulcerati&n,  or  gangrene,  after  which  the 
destroyed  tissue  may  be  replaced  by  scar  tissue  (repair). 

The  varieties  of  inflammation  are:  Acute,  which  is  sudden  in 
onset  and  runs  a  severe  course;  subacute,  which  is  more  tardy  and  less 
severe  than  the  acute;  chronic,  which  is  of  a  low  grade  and  lasts  for  a 
long  time;  sthenic,  a  robust  inflammation  in  a  robust  individual; 
asthenic,  or  adynamic,  a  low  grade  inflammation  in  an  old  or  a  de- 
bilitated individual;  parenchymatous,  in  which  the  parenchyma  or 
secreting  cells  of  an  organ  are  affected;  interstitial,  involving  the 
connective  tissue  of  an  organ;  traumatic,  due  to  an  injury;  idiopathic, 
in  which  the  cause  cannot  be  found;  simple,  due  to  non-bacterial 
irritation;  infective,  due  to  bacteria;  serous,  characterized  by  a 
profuse  exudation  of  serum;  plastic,  adhesive,  or  fihrinous,  in  which 
the  exudate  causes  adjacent  organs  to  adhere;  purulent,  phlegmonous, 
or  suppurative,  characterized  by  the  formation  of  pus;  hemorrhagic, 
in  which  the  exudate  contains  considerable  blood;  catarrhal,  afifecting 
mucous  membranes  and  causing  an  increased  flow  of  mucus;  croupous, 
or  pseudomembranous,  characterized  by  the  formation  of  a  false 
membrane  consisting  of  fibrin  and  cells;  diphtheritic,  in  which  the 
false  membrane  is  formed  from  the  tissues  rather  than  from  the 
exudate;  gangrenous,  resulting  in  gangrene;  and  sympathetic,  reflex, 
or  metastatic,  when  the  process  appears  in  a  distant  tissue,  as  in- 
flammation of  the  breast,  ovary,  or  testicle  following  mumps. 

The  symptoms  of  acute  inflammation  are  local  and  constitutional. 
When  the  symptoms  are  slight  or  absent,  e.g.,  in  some  instances  of 
inflammation  of  Peyer's  patches  in  enteric  fever,  the  condition  is 
called  latent. 

The  local  symptoms  are  pain,  heat,  redness,  swelhng,  and  dis- 
ordered function  (dolor,  calor,  rubor,  tumor,  functio  Icesa). 

Pain  is  due  to  pressure  upon  the  nerve  terminals  by  the  dilated 
vessels  and  the  exudate,  or  to  irritation  the  result  of  bacterial  toxins 
or  chemical  changes  in  the  part.     It  is  increased  by  pressure  with  the 


94  MANUAL  OF  SURGERY 

hand  {tenderness),  and  by  raising  the  blood  pressure,  e.g.,  by  placing 
the  inflamed  part  in  a  dependent  position;  in  organs,  such  as  the  eye, 
testicle,  and  bone,  which  are  covered  by  dense  fascia  or  fibrous 
tissue,  and  in  which  swelling  cannot  easily  occur,  the  pain  is  much 
more  severe.  In  viscera  covered  by  serous  membrane  the  pain  is 
dull  until  the  serous  membrane  is  reached,  when  it  becomes  severe 
and  lancinating.  Inflammatory  pain  is  slow  in  onset,  remains  in 
one  situation,  persists,  and  is  accompanied  by  other  signs  of 
inflammation. 

Heat  is  due  to  the  large  amount  of  blood  brought  to  the  inflamed 
area,  and  in  inflammations  on  the  surface  is  easily  appreciated  by  the 
hand.  The  temperature  as  shown  by  a  surface  thermometer,  how- 
ever, is  never  greater  than  that  of  the  blood  in  the  internal  organs 
hence  as  a  symptom  local  heat  is  of  value  in  superficial  inflammation 
only. 

Redness  is  due  to  the  increased  amount  of  blood.  In  the  early 
stages  it  is  bright,  and  returns  with  great  rapidity  after  the  relief  of 
pressure,  showing  an  active  circulation;  as  the  velocity  of  the  blood 
stream  decreases,  it  becomes  more  dusky,  and  returns  more  slowly 
after  the  removal  of  pressure.  During  the  stage  of  stagnation  it  may 
be  impossible  to  remove  the  color  by  pressure.  In  avascular  tissue 
the  redness  is  seen  at  the  edges  of  the  part.  In  inflammation  of  the 
iris  it  is  absent  owing  to  the  amount  of  pigment  in  that  structure.  In 
non-vascular  tissues  and  in  serous  membranes  the  inflamed  part  may 
be  white;  when  a  number  of  red  corpuscles  have  been  forced  into  the 
tissues,  there  may  be  yellowish  discoloration. 

Swelling  is  due  partly  to  the  dilatation  of  the  vessels,  but  princi- 
pally to  exudation  and  cell  proliferation.  It  varies  with  the  severity 
of  the  inflammation  and  the  structure  of  the  part,  and  as  a  rule  is  in 
inverse  proportion  to  the  severity  of  the  pain;  in  regions  covered  by 
dense  fascia  it  is  more  marked  in  adjacent  parts,  as  is  illustrated  by 
the  puffiness  of  the  back  of  the  hand  in  palmar  abscess.  The  swelling 
pits  on  pressure  {edema)  and  is  at  first  soft,  becoming  harder  with 
coagulation  of  the  exudate  and  cellular  proliferation;  late  softening 
indicates  suppuration. 

Disordered  function  is  due  to  pain,  swelling,  or  to  chemical  changes 
in  the  cells.  It  may  be  expressed  as  increased  action  (frequent 
micturition  in  cystitis),  decreased  action  (small  amount  of  urine  in 
nephritis),  absence  of  action  (intestinal  paresis  in  peritonitis)  or 
perverted  action  (delirium  in  encephalitis).  Sometimes,  notably  in 
nervous  structures,  the  action  is  at  first  increased  owing  to  irritation, 
and  then,  owing  to  the  pressure  of  the  exudate,  decreased  or  abol- 


INFLAMMATION  95 

ished.  Muscular  rigidity,  which  is  often  an  iiiii)()rtant  sign  in  sur- 
gical inflammations,  is  due  to  altered  function  the  result  of  pain. 

Under  'Tain,"  "Local  Temperature,"  "Color,"  "Edema,"  and 
"Absent  Motion,"  Chap.  I,  will  be  found  additional  remarks  on 
these  symptoms. 

The  constitutional  symptoms  vary  with  the  cause,  severity,  and 
extent  of  the  inflammation,  and  the  part  involved.  In  the  milder 
forms  they  are  sHght  or  absent.  In  simple  inflaipmations  they  are 
due  to  the  absorption  of  flbrin  ferment  liberated  by  the  degenerating 
leukocytes,  hence  identical  with  those  of  aseptic  fever  (q.v.);  in 
bacterial  inflammations  to  the  absorption  of  toxins,  or  toxins  and 
bacteria,  hence  identical  with  those  of  sepsis  (q.v.). 

The  treatment  of  inflammation  is  local  and  constitutional. 

Local  treatment  consists  in  (A)  reducing  the  hyperemia  and 
(B)  promoting  the  absorption  of  the  exudate. 

A.  Reduction  of  hyperemia  may  be  eiTected  by  (i)  removing 
the  cause,  (2)  rest,  (3)  elevation,  (4)  local  blood  letting,  and  (5) 
cold. 

1.  Any  causative  irritation  should  be  removed,  e.g.,  a  foreign 
body  in  the  conjunctiva  producing  conjunctivitis,  a  stone  in  the 
bladder  causing  cystitis.  Micro-organisms  are  removed  by  proper 
incisions  and  disinfection.  In  some  cases,  e.g.,  appendicitis,  the 
inflamed  part  is  excised. 

2.  Rest  should,  as  far  as  possible,  be  both  physical  and  physio- 
logical. It  diminishes  the  amount  of  blood  taken  to  the  part, 
prevents  the  irritation  of  motion,  and  hinders  diffusion  of  the  infec- 
tion. Physical  rest  is  obtained  in  arthritis  by  means  of  splints,  in 
pleuritis  by  strapping  the  chest;  physiological  rest,  in  inflammations 
of  the  eye  by  dark  glasses,  in  nephritis  by  purgatives  and  diaphoretics, 
in  inflammation  of  the  brain  by  sedatives.  In  severe  inflamma- 
tions rest  in  bed  is  of  value,  in  that  it  lessens  the  number  of  heart 
beats,  and  thus  decreases  the  quantity  of  blood  pumped  into  the 
inflammatory  area.  Rest  may  be  secured  also  by  relaxation,  e.g., 
extension  in  coxalgia,  semi-flexion  of  the  knee  in  inflammation  of 
that  joint. 

3.  Elevation  reduces  hyperemia,  lessens  pain,  and  limits  exuda- 
tion. It  is  particularly  applicable  in  inflammations  of  the  extremi- 
ties, but  may  be  used  also  in  other  regions,  e.g.,  raising  the  head 
on  a  pilldw,  supporting  the  breast  by  a  bandage,  elevating  the  testicle 
with  a  suspensory  bandage. 

4.  Local  blood  letting  may  be  carried  out  by  punctures,  scarifica- 
tion, incision,  leeching,  and  cupping.     Aseptic  punctures  relieve  ten- 


96  MANUAL  OF  SURGERY 

sion  by  allowing  blood  and  exudate  to  escape,  and  are  useful  in  parts 
which  are  greatly  swollen  and  in  which  incisions  are  not  indicated. 
Scarification,  or  the  making  of  small  superficial  incisions,  is  used  for 
the  same  purpose.  Free  incisions,  entering  deeply  into  the  inflam- 
matory mass,  are  indicated  when  suppuration  is  threatened,  when 
pus  is  actually  present,  and  when  the  tension  is  so  great  that  gan- 
grene is  feared.  Leeches  should  never  be  used,  because  there  are 
cleaner  and  better  ways  for  removing  blood  and  exudate.  Cupping 
is  used  to  draw  blood  up  under  the  skin  (dry  cupping),  or  actually  to 
remove  it  from  the  tissues  (wet  cupping).  Dry  cupping  may  be 
accomplished  by  greasing  the  edge  of  a  glass,  and  igniting  a  small 
piece  of  blotting  paper,  soaked  with  alcohol,  which  has  been  placed  in 
the  bottom  of  the  glass.  As  soon  as  the  flame  disappears,  the  edge 
of  the  glass  is  pushed  against  the  skin;  the  tissues  are  sucked  up  as  the 
air  in  the  glass  cools  and  contracts.  There  are  special  instruments 
made  for  this  purpose,  in  which  a  vacuum  is  created  by  means  of  a 
rubber  bulb.  The  bulb  is  emptied  of  air  and  the  glass  applied  to  the 
skin;  when  the  hand  is  removed  from  the  bulb,  the  tissues  are  pulled 
up  into  the  glass.  Wet  cupping  is  performed  in  the  same  manner  as 
dry  cupping,  except  that  the  skin  is  previously  scarified  or  punc- 
tured, so  that  a  certain  amount  of  blood  is  drawn  from  the  tissues. 
The  '''artificial  leech^'  is  a  syringe-like  instrument  which  draws  blood 
from  a  part  after  previous  scarification.  Because  of  its  hygroscopic 
powers,  glycerin  may  be  used  for  depletion.  Cataplasma  kaolini, 
which  is  composed  of  kaolin,  glycerin,  boric  acid,  thymol,  methyl 
salicylate,  and  oil  of  peppermint,  is  used  as  a  local  application  for  its 
depletive  effect. 

5.  Cold  contracts  the  vessels,  acts  as  an  anesthetic,  and  is  indi- 
cated in  the  early  stages  of  inflammation.  After  the  occurrence  of  ex- 
udation it  hinders  the  evolution  of  the  process  and  prevents  absorption. 
It  should  be  apphed  continuously,  not  intermittently.  Intense  cold 
applied  for  a  long  time  may  result  in  sloughing,  hence  should  be  used 
with  great  caution  at  the  extremes  of  life  and  in  the  debiUtated. 
Wet  cold  is  not  as  easily  managed  as  dry  cold  and  is  more  depressing 
to  the  tissues,  but  is  very  useful  at  the  onset  of  sthenic  inflammations. 
Over  the  part  may  be  suspended  a  reservoir  filled  with  cold  water, 
from  which  a  strip  of  gauze  acting  as  a  wick  descends  to  the  inflamed 
part.  If  there  is  a  breach  in  the  skin,  the  solution  should  be  sterile  or 
antiseptic.  A  Kelly  pad  or  a  piece  of  mackintosh  should  be  placed 
beneath  the  part,  to  direct  the  fluid  into  a  receptacle  beside  the  bed. 
Cold  compresses  are  frequently  employed  in  inflammations  of  the 
eye.     Two  or  three  small  pads  of  gauze  are  put  on  a  cake  of  ice;  as 


INFLAMMATION  97 

soon  as  the  \ydd  which  has  been  placed  on  the  eye  becomes  warm,  it  is 
replaced  by  a  fresh  one,  and  the  old  one  is  placed  on  the  ice.  Cold 
may  be  generated  also  by  evaporating  lotions,  such  as  lead-water  and 
laudanum  ( i  oz.  each  of  licjuor  plunihi  subacetatis  dilutus  and  tinc- 
tura  opii  to  i  pint  of  water),  equal  parts  of  alcohol  and  water,  and  a 
solution  of  ammonium  chlorid  in  water  (i  to  2  drams  to  a  pint); 
these  solutions  may  be  applied  by  means  of  cloths  laid  on  the  part, 
or  b\'  means  of  a  reservoir  and  wick  as  described  above.  Dressings 
containing  an  evaporating  lotion  should  never  be  covered  with  wax 
paper,  because  evaj)oration  is  thus  prevented.  Dry  cold  may  be 
appHed  by  means  of  tin  cans,  bottles,  bladders,  etc.,  filled  with 
ice  water,  or  by  the  rubber  ice  cap,  all  of  which  should  be  protected 
by  a  covering  of  flannel.  An  inflamed  part  may  be  covered  or 
enveloped  wdth  a  coil  of  rubber  tubing  through  which  ice  water  is 
constantly  moving  by  syphonage.  The  same  principle  is  utilized  in 
Leiter's  tubes,  which  consist  of  a  coil  of  narrow  leaden  pipes  made  to 
fit  various  regions  of  the  body. 

Bier's  treatment  directly  antagonizes  the  principles  set  forth 
above.  Bier  beHeves  the  increased  number  of  leukocytes  and  the 
increased  amount  of  bacteriolytic  blood  serum  to  be  helpful  rather 
than  harmful,  and  therefore  seeks  to  produce  a  ''passive  hyperemia" 
by  constriction  above  the  inflamed  area,  or  by  a  suction  apparatus 
(which  acts  like  a  cup)  in  regions  in  which  constriction  is  inapplicable. 
The  vacuum  apparatus  also  draws  pus  and  sloughs  from  an  inflamed 
wound.  It  is  applied  for  3  minutes,  then  removed  for  5  minutes, 
this  procedure  being  repeated  for  three-fourths  of  an  hour  each 
day.  In  the  extremities  a  rubber  bandage  is  placed  above  the 
affected  part  and  drawn  tight  enough  to  retard  the  venous  return, 
without  interfering  with  the  arterial  circulation.  If  white  edema, 
coldness,  or  anesthesia  result,  the  constriction  is  too  tight.  The 
bandage  remains  in  a  place  a  number  of  hours  each  day,  sometimes 
as  long  as  twenty-two,  and  should  markedly  lessen  pain.  In  the 
presence  of  suppuration  a  small  incision  is  made  and  the  wound  is  not 
packed  with  gauze.  The  pus  is  at  first  increased  in  amount  and  then 
rapidly  disappears.  The  method  appears  to  be  of  some  value  in  mild 
and  well  localized  infections,  but  distinctly  harmful  in  virulent  and 
spreading  inflammations,  diabetes,  and  atheroma.  It  is  suited  only 
for  cases  which  are  under  constant  surveillance,  and  it  requires  sorne 
skill  and  judgment  for  its  proper  application. 

B.  Absorption  is  promoted  by  (i)  compression,  (2)  massage, 
(3)  astringents  and  sorbefacients,  (4)  heat,  (5)  douches,  and  (6) 
counterirritation. 


98  MANUAL  OF  SURGERY 

(i)  Compression,  judiciously  applied  and  carefully .  watched, 
may  be  used  in  the  first  stage  of  inflammation  to  limit  the  swelhng 
and  give  the  paralyzed  vessels  a  chance  to  recover  themselves. 
Firm  compression  before  swelling  has  fully  developed  increases  pain 
and  may  result  in  gangrene.  At  a  later  period  it  hastens  absorption 
and  is  a  measure  of  great  value.  In  acute  cases  compression  should 
be  elastic,  the  part  being  thickly  covered  with  loose  gauze  or,  better, 
cotton,  and  bandaged  from  the  end  of  the  extremity  to  above  the 
point  of  inflammation.  In  the  terminal  stage  of  acute  inflammation 
and  in  subacute  and  chronic  inflammation,  firm  compression  with  a 
thin  rubber  bandage,  adhesive  plaster  strapping,  tampons,  or  a  shot 
bag  are  frequently  employed. 

(2)  Massage  finds  its  chief  value  in  the  treatment  of  subacute  or 
chronic  inflammation  about  joints.  Effleurage  consists  in  rubbing 
the  limb  with  the  hand,  emphasis  being  placed  upon  the  upstroke  so 
as  to  encourage  the  flow  of  blood  and  lymph  from  the  part.  Petris- 
sage, or  kneading,  and  tapotement,  or  tapping,  also  quicken  the  circu- 
lation and  hasten  absorption.  Care  should  be  exercised  in  advising 
compression  and  massage  in  the  treatment  of  phlebitis  or  other 
inflammations  in  which  there  is  danger  of  dislodging  a  clot,  and 
also  in  individuals  with  atheromatous  arteries  or  tuberculous  foci. 

(3)  Astringents  are  largely  used  in  inflammations  of  mucous 
membranes.  Silver  nitrate,  pure  or  in  a  strong  solution,  coagulates 
the  superficial  albumen,  and  forms  a  protective  shield  for  the  parts 
beneath.  Weaker  solutions  of  the  silver  salts  are  frequently  employed 
as  astringent  antiseptics  in  the  treatment  of  inflammation  of 
the  urinary  tract.  The  efficiency  of  lead-water  and  laudanum  de- 
pends partly  upon  the  astringent  effect  of  the  lead-water.  Tincture 
of  iodin  should  never  be  placed  on  acutely  inflamed  tissues,  because 
of  its  irritating  qualities,  but  it  is  often  employed  as  a  counterirritant 
in  deep-seated  inflammations.  Its  absorptive  powers  when  applied 
locally  are  probably  slight  although  it  is  often  used  as  a  sorbefacient 
in  the  form  of  an  ointment.  Ichthyol  may  be  used  in  the  form 
of  an  ointment  as  strong  as  50  per  cent.,  remembering,  however,  that 
it  occasionally  produces  irritation  of  the  skin;  or  it  may  be  sprayed  or 
painted  upon  a  part,  in  the  strength  of  i  dram  to  the  ounce  of  water. 
Mercurial  ointment  is  often  employed  in  chronic  inflammation. 
If  used  for  a  long  time,  it  should  be  diluted  one-half  or  one-fourth,  as 
the  pure  ointment  may  vesicate  the  skin  or  salivate  the  patient. 
Belladonna  ointment  is  another  valuable  sorbefacient,  especially 
when  combined  with  equal  parts  of  ichthyol,  mercurial  ointment,  and 
vaselin  or  lanolin. 


INFLAMMATION  99 

(4)  Heat  is  rarely  used  in  the  first  stage  of  inflammation,  because 
the  amount  necessary  to  contract  the  vessels  is  too  great  for  comfort; 
that  which  is  comfortable  to  the  patient  relaxes  the  tissues,  lessens 
tension,  relieves  pain,  assists  absorption,  and  in  the  presence  of 
bacteria  hastens  suppuration.  In  inflammations  below  the  surface 
it  acts  as  a  counterirritant  by  diverting  blood  from  the  affected  part. 
It  is  applied  as  fomentations,  poultices,  baths,  or  as  dry  heat.  The 
fomentation,  or  stupe,  is  a  piece  of  flannel,  spongiopiline,  or  similar 
material,  soaked  in  a  hot  liquid,  which  may  be  water,  lead-water 
and  laudanum,  turpentine  and  water,  etc.,  or  an  antiseptic  solution 
{antiseptic  fomentation) .  The  flannel  is  wrung  out  until  almost  dry, 
then  applied  to  the  part  and  covered  with  some  insulating  material, 
such  as  wax  paper  or  oiled  silk,  which  will  retain  the  heat;  over  this 
may  be  placed  a  hot  water  bag,  which  is  refilled  as  often  as  may  be 
necessary.  In  a  turpentine  stupe  from  i  to  20  drops  of  turpentine  are 
sprinkled  upon  the  flannel.  A  poultice,  or  cataplasm,  may  be  made  of 
arrow  root,  bread,  bran,  potatoes,  hops,  starch,  slippery  elm,  turnips, 
and  many  other  such  materials,  but  flaxseed  is  the  substance  usually 
employed.  Charcoal  poultices  are  sometimes  used  for  deodorizing 
foul  ulcers.  The  selected  material  is  made  into  a  thick  paste  with 
hot  water  (yeast,  lead-water  and  laudanum,  or  an  antiseptic  solu- 
tion), spread  upon  muslin,  lint,  or  linen,  to  the  thickness  of  a  fourth 
or  half  inch,  and  covered  with  gauze,  or  coated  with  olive  oil,  so  that 
it  will  not  stick  to  the  skin;  oiled  silk  or  wax  papei  is  placed  over  the 
poiiltice  to  prevent  evaporation  and  loss  of  heat.  The  poultice 
should  be  changed  about  every  two  hours.  Poultices  should  never 
be  employed  where  there  is  an  open  wound;  if  heat  and  moistuie  are 
desired  in  such  cases,  as  for  the  separation  of  a  slough,  the  antiseptic 
fomentation  should  be  used.  A  general  warm  hath  is  sometimes  used 
in  extensive  burns,  partial  baths  in  badly  infected  wounds.  The 
sitz  bath,  or  hip-bath,  is  of  value  in  pelvic  and  abdominal  inflamma- 
tions. Dry  heat  may  be  obtained  by  heating  sand  bags,  salt  bags, 
cloths,  or  bricks;  by  bottles,  cans,  bladders,  or  rubber  bags  filled  with 
hot  water;  and  by  means  of  rubber  or  leaden  tubing,  as  described 
under  cold.  The  hot  air  apparatus  is  chiefly  employed  in  chronic 
inflammatory  affections  of  joints.  The  Hmb  is  wrapped  in  lint  and 
placed  in  the  apparatus,  the  temperature  of  which  may  be  raised  as 
high  as  3oo°F.  The  part  may  be  baked  for  one  hour  several  times  a 
week.  Radiant  heat,  generated  by  a  number  of  electric  bulb-lights, 
and  diathermy  also  are  employed  for  the  same  purposes  as  the  baking 
machine. 

5.  The  douche  is  a  stream  of  water  used  for  flushing,  for  conveying 


lOO  MANUAL  OF  SURGERY 

heat,  cold,  or  medicaments,  or  for  the  mechanical  effect  produced  by 
the  stream  directed  against  the  tissues.  Hot  vaginal  douches  are  of 
great  value  in  pelvic  inflammations,  and  douches  are  useful  also  in 
other  cavities  of  the  body.  The  ''Scotch  douche''  is  of  service  in  low- 
grade  chronic  inflammation;  it  consists  in  alternately  pouring  hot 
and  cold  water  upon  a  part.  The  heat  relaxes  and  the  cold  contracts 
the  vessels,  which  are  strengthened  by  this  form  of  exercise. 

6.  Counterirritation  is  the  process  whereby  a  structure  is  affected 
reflexly  by  means  of  an  irritant  at  a  distant  point.  It  relieves  pain, 
promotes  absorption,  and  is  used  principally  in  chronic  inflammation. 
Irritants,  such  as  silver  nitrate,  tincture  of  iodin,  and  copper  sulphate, 
are  sometimes  applied  to  stimulate  a  sluggish  area  of  inflammation 
into  activity.  Blisters  {epispastics)  are  produced  by  confining  chloro- 
form beneath  oiled  silk  or  a  watch  glass,  by  croton  oil,  by  ammonia 
mixed  with  an  equal  part  of  some  ointment  base,  and  by  cantharidal 
collodion  or  cantharidal  plaster  (fly  blister).  A  blistering  plaster 
is  moistened  with  sweet  oil,  and  applied  after  the  skin  has  been  shaved 
and  washed  with  soap  and  water.  A  blister  usually  forms  in  from 
five  to  six  hours,  in  tender  skins  in  a  much  shorter  period;  it  should 
be  punctured  with  an  aseptic  needle  and  dressed  with  a  bland  oint- 
ment. Frictions  with  stimulating  liniments  do  good  by  their  counterir- 
ritation and  massage.  Rubefacients,  e.g.,  mustard,  spice,  or  capsicum 
plaster,  and  turpentine  stupes,  produce  redness  of  the  skin.  Mus- 
tard plasters  come  already  prepared,  it  being  necessary  simply  to 
dip  them  in  warm  water  before  application.  A  mustard  plaster 
may  be  made  by  mixing  equal  parts  of  mustard  and  flour,  with  a 
little  vinegar  or  water,  the  paste  being  spread  upon  a  cloth  and 
covered  with  gauze.  The  addition  of  the  white  of  an  egg  prevents 
vesication.  When  a  more  severe  form  of  counterirritation  is  required, 
the  hot-iron  {actual  cautery),  or  escharotics  {potential  cautery),  such 
as  antimonial  ointment,  caustic  potash,  or  arsenical  paste,  may  be 
applied.  The  cautery-iron  is  heated  in  a  fire,  and  in  an  emergency 
may  be  improvised  from  a  telegraph  wire,  a  curling-iron,  or  a  poker. 
Much  more  convenient  is  the  electric  cautery,  or  in  the  absence  of 
this,  the  Paquelin  thermocautery  (Fig.  55).  After  heating  the  plati- 
num point  (a)  over  an  alcohol  lamp,  benzine  vapor  is  blown  from 
the  bottle  into  the  point  by  the  rubber  bulb  (b),  care  being  taken  to 
keep  the  heated  point  higher  than  the  bottle  lest  an  explosion  occur. 
The  more  rapidly  the  bulb  is  squeezed,  the  hotter  will  be  the  tip. 
For  counterirritation  the  cautery  should  be  red  hot  and  allowed  to 
touch  the  skin  lightly;  it  should  not  be  used  over  a  bony  prominence, 
a  large  nerve,  or  a  blood  vessel. 


INFLAMMATION 


lOI 


Constitutional  treatment  may  not  l)e  needed  in  trivial  inllamma- 
tions;  in  the  severer  forms  of  the  acute  variety  the  treatment  is  that 
of  sepsis  (q.v.).  Excepting  the  urinary  antiseptics  drugs  are  seldom 
given  by  mouth  to  influence  directly  the  activity  of  bacteria.  The 
internal  remedies  for  hastening  absorption  are  mercury  and  the  iodids, 
especially  in  chronic  inflammation.  The  same  rule  holds  good  in 
the  general,  as  in  the  local,  treatment  of  inflammation,  to  And  the 
cause  and  try  to  remedy  it.  Many  cases  of  chronic  inflammation  are 
tuberculous,  syphilitic,  gouty,  or  rheumatic,  and  poor  results  in  the 
local  treatment  of  acute  inflammation  may  be  due  to  some  general 
disorder,  such  as  Bright's  disease  or  diabetes.  These  constitutional 
affections  should,  of  course,  receive  appropriate  treatment.  Tonics, 
such  as  iron,  quinin,  and  strychnin  will  be  found  of  value  in  most 
forms  of  inflammation,  both  acute  and  chronic.     In  certain  inflamma- 


FlG.    55. —  Paquelin  thermocautery. 

tions  of  bacterial  origin  vaccins  or  serotherapy  may  be  tried.  The 
serum  treatment  of  specific  diseases  is  referred  to  on  subsequent 
pages. 

REPAIR 

Destroyed  tissue  is  usually  replaced  by  fibrous  tissue  {repair), 
and  not  by  the  highly  specialized  cells  characteristic  of  the  tissue 
(^regeneration) .  Repair  takes  place  most  rapidly  in  healthy  vascular 
tissues  which  have  been  carefully  brought  together,  kept  aseptic, 
and  put  at  rest.  Repair  is  hindered  by  infection,  strong  antiseptics, 
motion,  lack  of  blood  supply,  separation  of  the  tissues,  e.g.,  as  the 
result  of  gaping,  inversion  of  epithelial  surfaces,  or  the  interposition 
of  foreign  bodies,  and  by  many  constitutional  diseases,  prominent 
among  which  are  syphilis,  tuberculosis,  nephritis,  diabetes,  and 
carcinomatous  cachexia. 


I02  MANUAL  OF  SURGERY 

The  first  ot  the  phenomena  of  repair  are  identical  with  those  of 
inflammation,  except  in  intensity,  hence  the  absence  of  cHnical  signs. 
Inflammation  is  a  pathological  process  that  may  or  may  not  end  in 
repair,  which  is  a  physiological  process.  There  is  a  shght  dilatation 
of  the  vessels,  exudation  of  Hquor  sanguinis,  and  the  escape  of  many 
leukocytes  and  a  few  red  cells  and  blood  plaques.  The  leukocytes 
devour  and  remove  devitalized  cells  and  blood  clot.  The  fixed 
connective-tissue  cells  and  the  endothelial  cells  proliferate  by  the 
indirect  method  (mitosis  or  karyokinesis).  These  new  cells  are  called 
fibroblasts,  or  indift'erent  cells,  and  form  a  mass  called  indift'erent 
or  embryonic  tissue.  The  leukocytes  wander  back  into  the  circulation 
or  are  devoured  by  the  fibroblasts.  From  the  walls  of  the  capillaries 
little  buds  of  protoplasm  shoot  out,  which  unite  with  similar  proc- 
esses from  other  vessels  and  become  canalized,  i.e.,  form  new  capil- 
laries; thus  vascularization,  or  organization,  of  the  mass  is  bought 
about,  and  the  new  tissue  is  spoken  of  as  granulation  tissue.  In 
regeneration  the  parenchyma  cells,  or  specialized  cells,  of  a  tissue  or 
organ  also  proliferate.  The  fibroblasts  elongate  and  develop  fibrillae, 
which  interlace  and  form  fibrous  tissue  (cicatricial  or  scar  tissue). 
Fibrous  tissue  is  at  first  red,  but  later  contracts,  compresses  the 
newly-formed  capillaries,  and  thus  in  the  course  of  time  becomes 
dense,  hard,  and  white.  In  wounds  of  the  skin  or  mucous  membrane 
the  gap  at  the  surface  is  covered  with  epidermis,  which  grows,  not 
from  the  granulation  tissue,  but  from  the  epithelium  at  the  margins 
of  the  wound. 

When  an  incised  wound  heals  without  suppuration,  the  process  is 
called  healing  by  first  intention,  or  primary  union.  The  bleeding  is 
checked  by  small  clots  in  the  mouths  of  the  vessels,  and  the  wound 
margins  are  glued  together  by  the  fibrin  of  the  extravasated  blood. 
The  small  amount  of  devitaHzed  tissue  and  blood  clot  is  soon  ab- 
sorbed, and  healing  progresses  as  described  above.  Healing  by 
second  intention,  or  by  granulation,  occurs  when  the  lips  of  a  wound 
are  separated  as  the  result  of  infection  or  the  loss  of  a  large  amount  of 
tissue.  In  the  former  instance  the  dead  tissue  is  ehminated  by 
sloughing  or  suppuration.  Many  of  the  fibroblasts  are  separated 
from  their  fellows  by  the  peptogenic  action  of  the  toxins  on  the 
intercellular  substance,  and  discharged  irom  the  wound  as  pus  cells. 
The  mass  of  cells  which  remains  becomes  vascularized,  forming 
granulation  tissue.  Each  granulation  is  made  of  a  series  of  capillary 
loops  surrounded  by  and  nourishing  fibroblasts.  Healthy  granula- 
tions are  bright  red,  smooth,  and  firm.  The  fibroblasts  inultiply, 
new  capillaries  are  formed,  and  finally  the  cavity  is  filled.     As  the 


INFLAMMATION  103 

granulations  grow  upward  the  fibroblasts  at  the  bottom  of  the  cavity 
become  fibrous  tissue,  which  contracts  and  lessens  the  size  of  the 
healing  area.  In  the  meantime  the  epithelium  of  the  edges  of  the 
wound  has  been  creeping  inward  by  a  proliferation  of  its  cells  {epi- 
dermization) .  If  granulations  grow  above  the  level  of  the  skin  {exu- 
henmt  f^raniilatioiis,  or  proud  flesh),  epithelial  proliferation  is  checked 
until  the  granulations  are  removed.  These  granulations  are  usually 
large,  pale,  flaboy,  and  edematous.  When  two  clean  granulating 
surfaces  unite  after  being  brought  together,  healing  by  third  intention 
is  said  to  occur.  Healing  by  organization  of  a  blood  clot  is  seen 
where  a  cavity  is  filled  with  an  aseptic  blood  clot.  The  process 
differs  in  no  respects  from  that  which  has  already  been  described. 
The  clot  acts  as  a  scaffolding  lor  the  granulations  and  is  gradually 
absorbed. 

In  the  repair  of  non-vascular  tissue  leukocytes  and  serum  come 
from  adjacent  tissues.  In  the  cornea  the  wound  is  at  first  glued 
together  by  fibrin,  which  is  later  replaced  by  proliferated  corneal 
cells.  In  a  very  trivial  injury  the  resulting  tissue  may  be  transpar- 
ent; in  a  severe  injury  fibrous  tissue  forms  and  an  opaque  scar  results. 
After  an  incised  wound  of  cartilage  much  the  same  process  takes 
place,  but  the  chondral  cells  make  little  effort  at  regeneration,  and 
the  resulting  cicatrix  is  always  fibrous  tissue.  After  fracture  of 
cartilage,  however,  a  sort  of  callus  is  thrown  out,  which  may  become 
cartilaginous  or  even  bony. 

Skin  and  mucous  membrane  are  repaired  by  fibrous  tissue  covered 
by  epithelium;  the  deeper  layers  of  the  skin,  the  hair  follicles,  and  the 
sebaceous  and  sweat  glands  are  not  regenerated.  Wounds  involving 
the  cuticle  alone  are  not  followed  by  permanent  scars;  those  which 
pass  into  or  through  the  deep  skin  leave  a  permanent  scar. 

Blood  vessels,  after  division  or  ligation,  are  closed  by  clot,  w^hich 
is  finally  replaced  by  fibrous  tissue.  After  aseptic  ligation  it  is 
claimed  that  heahng  may  occur  without  the  formation  of  a  thrombus 
(chap.  xv).  Repair  of  tendon  and  muscle  takes  place  by  fibrous 
tissue,  but  striped  (voluntary)  muscular  fiber  may  regenerate 
after  trivial  wounds.  Bone  is  repaired  by  bone  (chap.  xLx).  Xerves 
may  regenerate  (chap.  xvii).  Regeneration  of  the  brain  is  possible 
but  very  rare  (chap,  xxi,  xxii).  Lymphatic  tissue  and  glandular 
organs  may  regenerate,  but  in  the  latter,  destroyed  parenchyma 
is  usually  replaced  by  scar  tissue.  In  general  it  may  be  stated 
that  nature  usually  replaces  all  losses  with  one  material,  viz., 
fibrous  tissue,  hence  the  nearer  a  structure  is  histologically  to  con- 
nective tissue  the  more  apt  it  is  to  regenerate,  since  with  connective 


I04 


MANUAL  OF  SURGERY 


tissue,  repair  and  regeneration  are  synonymous.  Thus,  skin,  fat, 
fascia,  tendons,  blood  vessels,  peritoneum,  cartilage,  and  bone  are 
often  reproduced,  while  highly  developed  cells  like  those  of  the  paren- 
chymatous organs  and  the  central  nervous  system  are  seldom 
regenerated. 

A  normal  scar,  or  cicatrix,  is  at  first  smooth,  hard,  and  owing  to 
its  vascularity,  red  in  color.  Later,  in  obedience  to  the  contraction 
of  the  fibrous  tissue,  it  becomes  white  (avascular),  more  dense,  and 
often  wrinkled.  It  is  insensitive,  because  of  the  absence  of  nerves, 
and  contains  no  lymphatics.  The  itching  or  burning  sensation 
sometimes  referred  to  a  scar  is  due  to  irritation  of  the  nerve  fila- 


FiG.   56. — Cicatricial  contraction  following     FiG.   57. — Cicatricial  contraction  following 
a  burn;  side  view.  a  btirn;  front  view. 

ments  in  the  adjoining  skin  or  subjacent  tissues.  The  principal 
deviations  from  the  normal  are  listed  below. 

Discoloration  of  a  copperish  hue  may  occur  in  syphilis,  a  blue  or 
brown  pigmentation  after  the  heahng  of  a  varicose  ulcer.  In  other 
cases  discoloration  may  be  due  to  foreign  substances,  e.g.,  gunpowder, 
particles  of  coal,  or  to  partial  retention  of  normal  pigment,  e.g.,  in 
the  negro.  Excision,  followed  by  careful  apposition  of  the  wound 
with  a  subcuticular  suture,  is  indicated  in  some  of  these  cases,  as 
well  as  in  some  cases  in  which  disfigurement  is  due  solely  to  the  shape 
and  site  of  the  scar,  e.g.,  a  wide,  irregular  cicatrix  on  the  face  or  neck. 

Excessive  contraction  is  most  frequent  after  extensive  superficial 
wounds,  notably  burns,  the  granulation  tissue  reaching  the  surface 
and  undergoing  conversion  into  fibrous  tissue  long  before  the  com- 


INFLAMMATION  105 

l^ik'lion  of  opidcrniizalion,  hence  the  imi)()rtance  of  the  prophylactic 
measures  advised  in  the  section  on  ''Burns."  On  the  surface  of 
the  body  the  evils  of  contraction  are  most  marked  about  the 
face,  the  neck  (Figs.  56.  57)  and  the  joints.  In  these  cases  libera- 
tion of  the  parts  by  proper  incisions,  and  tilling  the  resulting  gap 
by  a  plastic  operation,  is  to  be  considered.  In  the  canals  of  the  body 
contraction  results  in  stricture,  in  connection  with  nervous  tissue, 
pain,  spasm,  paralysis.  Contracting  adhesions  in  the  serous  cavities 
and  elsewhere  are  responsible  for  various  forms  of  mischief,  as  will  be 
pointed  out  on  subsequent  pages. 

Stretching  may  occur  when  recent  scar  is  subjected  to  an  almost 
continuous  strain,  thus  are  produced  the  post-operative  hernias 
of  the  abdomen.  Stretching  is  sometimes  utilized  as  a  therapeutic 
measure,  especially  in  the  treatment  of  strictures. 

Depression  may  be  due  to  adhesion  of  the  scar  to  deeper  struc- 
tures, especially  bone.  A  depressed  scar,  circular,  serpiginous,  or 
semilunar  in  shape  is  suggestive  of  syphilis. 

" Hypertrophic d"  scars  are  most  frequent  after  infected  wounds 
and  in  the  negro.  When  the  hyperplasia  continues  the  growth  is 
called  a.  false  keloid  (chap.  xiv). 

Painful  scars  are  due  to  the  pressure  of  the  contracting  tissue  on  a 
nerve  filament.  Relief  is  obtained  by  excising  the  painful  area,  or 
by  finding  and  excising  the  involved  nerve. 

Ulceration  is  prone  to  occur  in  scars,  because  of  their  lack  of 
nourishment,  and  for  the  same  reason  such  ulcers  are  difficult  to 
heal,  unless  the  scar  tissue  is  removed. 

EpitheUoma  may  develop  in  any  scar,  but  is  most  frequent  in 
those  exposed  to  constant  irritation,  and  in  those  following  X-ray 
burns.  Pain  and  lymphatic  metastases  are  absent,  so  long  as  the 
growth  is  confined  to  the  scar. 


CHAPTER  VII 
SUPPURATION 

Suppuration  is  the  liquefaction  of  the  products  of  inflammation, 
the  resulting  fluid  being  called  pus. 

The  cause  of  suppuration  is  almost  invariably  infection  with 
bacteria.  The  puriiloid  material  resulting  from  the  injection  of 
sterile  irritants,  such  as  mercury  and  croton  oil,  is  theoretically  not 
pus.  Constitutional  diseases  which  lower  the  resistance  of  the  tis- 
sues, especially  diabetes  and  nephritis,  predispose  to  suppuration. 
Locally,  injuries  in  which  the  tissues  are  bruised  or  lacerated  are 
prone  to  suppurate. 

The  Pyogenic  or  Pus  Producing  Bacteria. — The  staphylococcus 
pyogenes  aureus  is  an  amotile,  facultative  anaerobe,  grows  in  clusters 
like  grapes,  thrives  best  at  the  temperature  of  the  body,  is  normally 
present  on  the  skin,  in  the  nose,  mouth,  rectum,  and  vagina,  and 
represents  about  lo  per  cent,  of  the  germs  in  the  air  of  an  operating 
room;  hence  the  most  common  organism  generating  pus.  It  may 
remain  latent  in  ice  and  dry  pus  for  days;  in  the  human  body, 
especially  in  osteomyelitic  foci,  for  many  years.  It  produces 
golden-yellow  colonies  on  culture  media,  and  is  instantly  killed  by 
boiling  water.  It  is  strongly  leukotactic,  i.e.,  attracts  leukocytes 
from  the  blood;  hence  usually  causes  a  limited  infection  which  is 
walled  in  by  cell  barriers;  it  may,  however,  be  found  in  spreading 
suppurations  and  produce  fatal  results.  Staphylotoxin  causes 
degeneration  of  tissue  cells  and  constitutional  symptoms.  The 
staphylococcus  pyogenes  alhus  and  the  staphylococcus  pyogenes  citreus 
are  varieties  of  the  staphylococcus  pyogenes  aureus.  The  former, 
which  is  probably  identical  with  the  staphylococcus  epidermidis  alhus, 
shows  a  white  color  in  its  growth,  and  is  commonly  found  in  stitch 
abscesses,  the  normal  habitat  of  the  organism  being  upon  and  in  the 
crypts  of  the  skin;  the  latter  organism  produces  a  lemon-yellow  color. 
The  streptococcus  pyogenes  (chain  coccus)  is  identical  with  the  strep- 
tococcus erysipelatis.  It  is  an  amotile,  facultative  anaerobe,  grows 
best  at  the  temperature  of  the  body,  and  is  found  on  the  skin  and 
mucous  membranes  and  in  dust  and  sewage.  It  is  readily  killed 
by  the  usual  antiseptics,  but  may  remain  latent  in  ice  and  in  a  dry 

1 06 


SUPPURATION  107 

form  for  months.  It  sometimes  has  a  favorable  influence  on  sarcoma, 
but  as  a  secondary  invader  in  tuberculosis  and  other  infections  it 
increases  tissue  destruction  and  the  violence  of  the  general  symptoms. 
It  is  feebly  leukotactic,  consequently  produces  a  thin  watery  pus, 
readily  invades  the  lymph  channels,  and  causes  spreading  inflamma- 
tions and  widespread  suppuration.  Its  toxin  is  hemolytic  and  causes 
serious  constitutional  symptoms.  The  bacillus  coli  communis  is 
morphologically  identical  with  the  typhoid  bacillus.  It  is  a  plump 
straight  rod,  possesses  flagellae,  is  actively  motile,  is  a  facultative 
anaerobe,  and  generates  gas  with  a  fecal  odor.  It  normally  inhabits 
the  intestine  as  a  harmless  saprophyte,  but  becomes  pathogenic 
when  it  invades  damaged  tissue,  e.g.,  strangulated  bowel,  or  lodges 
in  foreign  soil,  e.g.,  in  the  gall  bladder  or  genito-urinary  apparatus. 
The  bacillus  pyocyaneus  is  frequently  present  in  wounds  and  ulcers 
which  are  not  dressed  regularly;  it  produces  green  or  blue  pus  and  is 
of  little  significance,  although  a  few  cases  of  general  infection  have 
been  reported.  It  is  aerobic,  motile,  having  a  polar  flagellum,  and  is 
found  in  water  and  in  the  alimentary  canal.  Other  pathogenic 
organisms  occasionally  found  in  suppurative  processes  are  the 
staphylococcus  cereus  albus,  staphylococcus  cereus  flavus,  staphylococcus 
flavescens,  micrococcus  tetragenus,  micrococcus  pyogenes  tenuis,  gono- 
coccus,  pneumococcus,  and  the  bacillus  of  typhoid  fever,  influenza,  and 
diphtheria.  Non-pathogenic  saprophytes  cause  putrefactive  changes 
in  foul  wounds.  The  bacillus  of  tuberculosis  and  the  ameba  coli  (the 
cause  of  tropical  dysentery  and  hepatic  abscess)  do  not  originate  true 
pus,  but  a  puruloid  material. 

Pyogenic  bacteria  usually  enter  the  tissues  through  wounds ;  they 
may,  however,  make  their  way  through  the  hair  follicles,  sebaceous 
glands,  or  sweat  ducts.  When  suppuration  occurs  in  a  subcutaneous 
lesion,  such  as  a  hematoma,  micro-organisms  reach  the  area  by  way 
of  the  blood,  probably  having  entered  the  circulation  through 
the  tonsils,  the  lungs,  or  the  intestinal  canal. 

The  pathology  of  suppuration  is  that  of  inflammation,  plus  the 
peptonizing  infloience  of  pyogenic  bacteria,  i.e.,  by  means  of  enzymes 
they  digest  or  liquefy  the  intercellular  portion  of  the  inflammatory 
exudate.  Staphylococci  and  other  organisms  of  low  virulence  give 
the  inflammatory  exudate  about  the  area  of  infection  a  chance  to 
organize  and  form  a  barrier  to  further  dissemination  thus  an  abscess 
is  formed.  Organisms  of  high  virulence,  such  as  the  streptococcus, 
prevent  coagulation  of  the  exudate,  and  the  infection  quickly  spreads. 
The  same  result  may  ensue  with  less  virulent  bacteria  when  the  tissues 
have  little  resistance. 


Io8  MANUAL  OF  SURGERY 

Pus  consists  of  liquor  pu  is  (liquefied  intercellular  exudate  and 
microbic  products)  and  pus  cells  (dead  and  dying  leukoc}'tes  and 
connective-tissue  cells). 

Varieties  of  Pus. — Normal  pus  is  generally  due  to  the  staphylo- 
coccus; it  tends  to  remain  localized,  and  the  tissues  from  which  it 
comes  quickly  recover  after  thorough  drainage  has  been  established. 
It  is  a  greenish-white,  creamy  fluid,  alkaline  in  reaction,  and  of  a 
specific  gravit}-  of  1030.  It  may  be  odorless  or  smell  like  paste. 
Tchoroiis  pus  is  watery,  acid,  and  very  irritating  to  the  tissues.  Blue 
pus  is  due  to  the  bacillus  pyocyaneus,  orange  pus  to  hematoidin 
crystals  the  result  of  degeneration  of  red  blood  corpuscles,  stinking 
pus  to  the  bacteria  of  putrefaction.  Fibrinous  pus  contains  flakes 
of  lymph;  sanious  pus,  blood;  serous  pus,  a  large  quantity  of  serum; 
muco-pus.  mucus.  Gas  producing  pus  is  due  to  the  bacil  us  of  malig- 
nant edema,  bacillus  aerogenes  capsulatus,  bacillus  coh  communis, 
or  other  saprophytes,  or  to  communication  with  one  of  the  air- 
containing  viscera.  Tuberculous  pus,  found  in  tuberculous  processes, 
and  gummy  pus,  the  result  of  a  degenerating  gumma,  are  not,  strictly 
speaking,  pus. 

Suppuration  occurs  on  epithehal  or  endothelial  surfaces,  or  in  the 
tissues.  Pyogenic  inflammation  of  a  mucous  membrane  (e.g., 
urethritis,  bronchitis)  may  subside  and  leave  the  structure  normal,  or 
eventuate  in  suppurative  destruction  (ulceration)  of  a  portion  of 
the  membrane.  When  pus  accumulates  in  a  ca\'ity  lined  with  endo- 
thehum.  or,  owing  to  obstruction  to  its  drainage,  in  a  duct  or  a  cavity 
lined  with  epithelium  the  condition  is  called,  according  to  its  location, 
pyosalpinx,  empyema  of  the  pleural  cavity,  of  the  gall  bladder,  of 
the  antrum  of  Highmore,  etc.,  although  from  a  clinical  standpoint 
it  is  an  abscess.  Suppuration  in  the  tissues  may  be  dift'use  (suppura- 
tive cellulitis,  which  is  described  on  a  later  page)  or  circumscribed 
(abscess). 

An  abscess  is  a  "circumscribed  cavity  of  new  formation  contain- 
ing pus."  Suppuration  begins  in  the  center  of  the  inflammatory 
area,  and  steadily  extends  by  melting  down  the  surrounding  em- 
bryonic tissue.  An  abscess  at  this  stage  exhibits  five  zones:  (i)  The 
pus,  (2)  a  zone  of  disintegrating  embryonic  tissue,  (3)  a  zone  of 
inflammatory  tissue  filled  with  leukocytes,  fibroblasts,  and  throm- 
bosed vessels,  hence  the  absence  of  hemorrhage  as  the  abscess 
spreads,  (4)  inflammatory  tissue  containing  many  leukocytes,  with 
the  blood  stream  in  the  stage  of  retardation,  and  (5)  a  zone  of  active 
hyperemia  with  beginning  exudation  (Fig.  58).  These  zones  increase 
in  size  as  the  abscess  enlarges,  not  in  mathematical  circles,  but  in  the 


SUPPURATION 


109 


direction  of  least  resistance,  until  finally  the  abscess  reaches  the 
surface  or  a  cavity  and  emjities  itself.  The  tissues  at  the  surface 
pass  throuji;!!  the  various  stages  of  inflammation  and  liquefy,  until 
ultimately  nothing  remains  but  a  very  thin  layer  which  is  pushed 
up  by  the  pus  below  {pointing),  giving  the  abscess  a  characteristic 
acuminate  appearance.  When  this  thin  layer  liquefies,  the  abscess 
"bursts"  and  spontaneous  evacuation  occurs.  After  an  abscess  has 
emptied  itself  or  ceased  to  spread,  the  inflammatory  phenomena 
subside,  and  the  embryonic  tissue  forming  its  walls  is  organized 
into  granulation  tissue;  at  this  stage  the  zones  of  an  abscess  are(i) 
the  pus  (2)  zone  of  granulation  tissue,  (3)  fibrous  tissue,  (4),  slightly 
hyperemic  normal  tissue. 

llie  varieties  of  abscesses  may  be  designated  according  to  the 
structure  involved,  as  lacunar,  involving  a  lacuna  of  the  urethra; 
follicular,  involving  a  follicle;  psoas,  travel- 
ing in  the  psoas  sheath;  thecal,  involving  a 
tendon  sheath;  bursal,  involving  a  bursa; 
brain:  pulmonary,  etc.  According  to  dura- 
tion an  abscess  may  be  acute  or  chronic 
(usually  tuberculous).  Among  other  terms 
used  to  describe  abscesses  are,  gravitating, 
wandering,  or  hypostatic  (traveling  from  one 
point    to    another,    e.g.,    psoas    abscess); 

diathetic  (due  to  some  constitutional  dis-  ,    J'""-   58.— Diagram   illus- 
trating   zones    in     spreading 

order) ;  atheromatous  (occurring  beneath  the  (upper  half)  and  healing  ab- 

.       .  .  ^       ,       ',•  \  T      1  /  scess  flower  half). 

mtima  m  endarteritis) ;  canalicular  (com- 
municating with  a  duct) ;  gangrenous  (the  surrounding  parts  become 
gangrenous) ;  tympanitic,  or  emphysematous  (containing  gas) ;  encysted 
(limited  by  adhesions  in  a  serous  cavity) ;  fecal,  or  stercoraceous  (com- 
municating with  the  bowel) ;  hematic  (containing  broken  down  blood) ; 
tropical  (in  the  liver  following  amebic  dysentery) ;  marginal  (near  the 
margin  of  anus);  pyemic,  metastatic,  embolic,  multiple,  or  miliary 
(due  to  septic  emboli) ;  milk  (in  the  breast  of  a  nursing  woman) ; 
shirt-stud  (the  cavity  of  a  deep  abscess  communicates  with  a  super- 
ficial abscess  by  a  narrow  sinus) ;  perforating  (breaking  into  some 
cavity) ;  ossifluent  (due  to  diseased  bone) ;  secondary  (occurring 
some  distance  from  the  infecting  lesion,  e.g.,  abscess  of  axilla 
after  infected  finger) ;  urinary  (due  to  extra vasated  urine) ;  residual 
(recurring  months  or  years  later) ;  syphilitic,  or  gummatous  (due  to 
syphilis) ;  Brodie's  (tuberculous  abscess  near  the  epiphyseal  line  of 
a  long  bone);  superficial  (above  the  deep  fascia);  and  deep  (below 
the  deep  fascia). 


no  MANUAL  OF  SURGERY 

The  S3miptoms  of  an  acute  abscess  are,  (i)  the  local  symptoms  of 
inflammation,  plus  fluctuation  and  pointing;  (2)  pressure  symptoms; 
and  (3)  constitutional  symptoms. 

1.  The  local  symptoms  of  inflammation  all  become  intensified; 
the  swelling  is  greater,  edema  more  marked,  heat  more  apparent, 
redness  more  dusky,  pain  more  severe  and  often  throbbing  in  charac- 
ter, and  the  function  of  the  part  is  lost  or  greatly  impaired.  As  the 
abscess  matures,  signs  of  fluctuation  manifest  themselves;  the  abscess 
becomes  acuminate,  pointing  occurs,  and  spontaneous  evacuation 
follows. 

2.  The  pressure  symptoms  depend  upon  the  size  and  seat  of  the 
abscess ;  in  the  cranium  an  abscess  produces  symptoms  of  compression 
of  the  brain;  in  the  tonsil,  dysphagia;  in  the  neck,  dyspnea.  Large 
blood  vessels,  especially  veins,  are  occasionally  compressed,  but  very 
rarely  opened  by  an  abscess. 

3.  The  consiitutional  symptoms  vary  from  a  slight  rise  in  tempera- 
ture to  the  severer  grades  of  septicemia  or  even  pyemia  (q.v.) .  Leu- 
kocytosis occurs  when  there  is  free  absorption  of  the  toxin  and  active 
resistance  of  the  tissues.  It  may  be  absent  in  trivial  suppurations, 
in  very  severe  forms  in  which  all  resistance  is  overcome,  and  in  those 
abscesses  of  a  subacute  nature  which  are  thoroughly  walled  in  by 
fibrous  tissue. 

The  diagnosis  of  a  superficial  abscess  is,  as  a  rule,  easily  made. 
A  suspected  abscess  near  a  large  blood  vessel  should  always  be 
carefully  investigated,  in  order  to  avoid  the  calamity  of  opening  an 
aneurysm.  The  differential  diagnosis  is  given  under  "Aneurysm." 
In  an  inflamed  cyst,  hematoma,  lipoma  or  other  benign  tumor,  the 
shape,  the  previous  history,  and,  if  necessary,  the  exploring  needle 
will  dispel  all  doubt.  An  encephaloid  carcinoma  and  a  round  celled 
sarcoma  may  be  hot,  soft,  of  recent  formation,  and  associated  with 
fever  and  leukocytosis.  However,  tenderness  is  usually  not  so 
pronounced  as  in  abscess,  and  the  veins  over  the  growth  are  enlarged 
and  increased  in  number.  In  some  cases  the  diagnosis  can  be  made 
only  by  exploratory  puncture  or  incision.  Other  conditions  that 
have  been  mistaken  for  acute  abscess  are  strangulated  hernia, 
erysipeloid,  and  erythema  nodosum;  these  conditions  are  described 
under  their  respective  headings.  The  diagnosis  of  chronic  abscess 
is  given  on  a  later  page. 

The  prophylactic  treatment  consists  in  the  thorough  disinfection 
of  all  abrasions  and  wounds.  In  severe  inflammations  early  incision 
will  occasionally  prevent,  or  at  least  limit,  the  formation  of  pus. 
Suppuration  is  often  encouraged  when  it  is  known  to  be  inevitable, 


SUPPURATION  III 

by  the  application  of  antiseptic  fomentations.  When  pus  is  once 
formed,  the  abscess  must  be  opened. 

The  antiseptic  prrparalions  before  incision  should  be  as  thorough 
as  before  any  operation,  because  of  the  danger  of  secondary  infection. 

Anesthesia  may  not  be  necessary,  in  which  case  the  knife  should 
be  sharp  and  the  hand  quick,  the  incision  being  so  made  that  if  the 
patient  draws  the  part  away  he  will  assist  rather  than  hinder  the 
surgeon.  Infiltration  anesthesia  is  too  painful  in  inflamed  tissues 
and  may  spread  infection.  Freezing  likewise  is  attended  by  pain, 
and  acts  only  on  the  skin.  Regional  anesthesia  (q.v.),  when  applic- 
able, is  the  best  form  of  local  anesthesia.  If  a  general  anesthetic  is 
desired  the  best,  if  only  an  incision  is  to  be  made,  is  nitrous  oxid. 

The  incision  should,  in  order  to  facilitate  drainage,  be  made, 
whenever  possible,  at  the  most  dependent  part  of  the  abscess. 
Important  structures  (e.g.,  vessels  and  nerves)  must  be  avoided  and, 
especially  on  the  face  and  the  neck  the  incision  should,  in  order  to 
render  the  subsequent  scar  inconspicuous,  be  made  in,  rather  than 
across,  the  natural  creases  of  the  skin.  When  an  abscess  is  situated 
in  a  dangerous  region,  such  as  the  neck,  one  may  employ  Hilton'' s 
method,  i.e.,  the  skin  and  deep  fascia  are  incised,  and  after  a  director 
has  been  pushed  into  the  cavity,  a  pair  of  closed  hemostatic  forceps  is 
passed  along  the  groove,  then  opened,  and  withdrawn  while  open  so 
as  to  dilate  or  tear  the  structures.  In  some  cases  a  counter-opening 
is  desirable  for  better  drainage,  or  for  through  and  through  irrigation. 
This  is  made  by  pushing  a  pair  of  forceps  against  the  opposite  wall 
of  the  abscess,  and  cutting  down  upon  the  end  with  a  knife. 

Exploration  of  the  abscess  cavity  with  the  fingei  may  lead  to  the 
discovery  and  the  removal  of  the  cause,  e.g.,  an  inflamed  appendix, 
a  foreign  body.  Squeezing  the  abscess  increases  the  inflammation, 
curetting  exposes  new  areas  to  infection. 

Disinfection  of  the  abscess  cavity  with  a  strong  antiseptic  is 
occasionally  indicated,  irrigation  with  salt  solution  is  often  desirable, 
but  antiseptics  and  irrigation  are  both  contraindicated  in  many  cases, 
particularly  when  the  abscess  is  in  the  cranium,  the  thorax,  oi  the 
abdomen. 

Drainage  may  be  effected  by  tubing,  gauze,  or  strips  of  rubber 
tissue. 

Dressings  should  be  changed  frequently  and  the  part  kept  at 
rest.  Heat  is  often  grateful  to  the  patient,  and  perhaps  there  is 
some  virtue  in  hot  fomentations  of  W  right's  solution  (sod.  chlorid 
4  per  cent.,  sod.  cit.  i  per  cent.,  in  water).  Sodium  chlorid  in 
hypertonic  solution  increases  the  exudation  of  lymph,  the  calcium 


112  MANUAL  OF  SURGERY 

salts  of  which  are  precipitated  by  sodium  citrate,  thus  removing  one 
of  the  elements  necessary  to  coagulation  and  ensuring  a  free  dis- 
charge. The  skin  must  be  protected  from  the  irritating  action  of  the 
sodium  citrate  by  vasehn,  and  the  solution  should  not  be  used  if  there 
is  a  tendency  to  oozing  of  blood  or  if  adhesions  are  desired.  Further, 
as  pointed  out  by  Crandon,  the  solution  should  be  discontinued  after 
36  or  72  hours,  since  prolonged  applications  lead  to  maceration  and 
to  indolence  in  heahng.  Xo  matter  what  dressing  is  employed,  if 
there  is  pain  severe  enough  to  interfere  with  sleep,  or  if  the  fever 
persists,  it  will  usually  be  found  that  drainage  is  insufificient  and 
that  a  larger  incision  is  indicated.  (For  Bier's  treatment  see 
inflammation). 

The  constitutional  treatment  is  that  of  sepsis  fq.v.). 

Chronic  abscess  may  follow  the  acute  form,  owing  to  encapsula- 
tion in  firm  fibrous  tissue.  In  the  brain,  the  breast,  and  the  tongue 
a  chronic  abscess  due  to  pyogenic  organisms  sometimes  forms  with- 
out preceding  acute  symptoms.  Chronic  abscess  may  be  due  also 
to  syphilis,  and  it  occurs  in  the  liver  from  infection  with  the  ameba 
coli.  The  term  chronic,  however,  when  applied  to  abscess,  usually 
means  tuberculous,  and  it  is  with  such  that  we  shall  deal  under  this 
heading.  The  abscess  is  formed  by  the  liquefaction  of  tuberculous 
tissue  (see  tuberculosis),  and  although  it  may  occur  in  any  portion  of 
the  body,  it  is  most  frequently  found  in  connection  with  bones,  joints, 
and  lymphatic  glands.  The  contents  is  not  true  pus.  but  a  yellowish- 
white,  odorless  fluid  containing  cheesy  masses  of  broken  down  tissue, 
coagulated  fibrin,  a  few  cells  undergoing  fatty  degeneration,  and 
frequently  cholesterin  crystals;  there  are  no  pyogenic  organisms,  and 
it  is  difficult  to  find  tubercle  bacilli,  although  injection  of  the  fluid 
into  guinea-pigs  produces  miliary  tuberculosis.  The  abscess  wall  is 
composed  of  two  layers;  the  inner  consists  of  large  flabby  granulations, 
grayish-yellow  or  purplish  in  color,  containing  miliary  tubercles,  and 
is  easily  detached  from  the  outer  layer,  which  is  composed  of  dense 
fibrous  tissue.     There  is  no  zone  of  inflammation. 

The  abscess  forms  without  inflammatory  symptoms,  hence  the 
term  cold  abscess.  Pain,  when  present,  is  due  more  to  pressure  upon 
surrounding  parts  than  to  the  disease  process  itself,  and  tenderness 
is  often  absent  in  the  abscess  itself,  although  usually  demonstrable 
in  the  tissue  primarily  diseased.  The  skin,  instead  of  being  red,  may 
be  paler  than  normal  (white  swelling) ;  while  softening  and  fluctuation 
are  usually  quite  evident,  owing  to  the  absence  of  inflammatory 
infiltration.  As  the  cause  of  trouble  is  often  deep,  the  pus  is  prone 
to  make  its  way  beneath  dense  fasciae,  and  to  appear  on  the  surface 


SUPPURATION  113 

at  a  point  far  distant  from  the  original  focus.  In  tuberculosis  of  the 
doisolunibar  spine  pus  ma}-  aj^jK'ar  in  the  lumbal  region,  iliac  region, 
perineum,  or  in  the  thigh.  When  a  tuberculous  abscess  suddenly 
appears  on  the  surface,  it  has  usually  come  from  a  distance  and 
perforated  some  resistant  structure,  as  its  formation  generally 
occupies  weeks  or  months.  An  untreated  tuberculous  abscess  may 
reach  the  surface  and  evacuate  itself,  or  be  walled  in  by  fibrous 
tissue.  In  the  latter  event  the  contents  become  putty-like  in 
consistency,  calcified,  or  absorbed  and  replaced  by  fibrous  tissue. 
When  such  an  area  again  becomes  active,  it  is  called  a  residual 
abscess. 

Constitutional  symptoms,  such  as  progressive  loss  of  weight  and 
pallor  are  often  absent  in  an  uncomplicated  tuberculous  abscess, 
and  there  is  no  leukocytosis.  After  the  abscess  bursts  and  other 
organisms  gain  entrance,  the  discharge  is  thick,  purulent,  and  in- 
creased in  amount,  and  constitutional  symptoms  of  mixed  infection 
are  present,  viz.,  those  of  hectic  fever  and,  if  the  suppuration  is  long 
continued,  amyloid  disease.  Secondary  infection  by  way  of  the 
blood  is  possible  but  rare. 

Hectic  fever  {chronic  septic  intoxication)  occurs  only  when  there  is 
mixed  infection;  it  may  be  found  not  only  in  the  tuberculous,  but  in 
any  case  in  which  there  is  protracted  suppuration.  It  is  due  to  the 
persistent  absorption  of  toxins,  and  is  characterized  by  a  daily 
afternoon  rise  in  temperature,  at  which  time  the  cheeks  become 
flushed  {hectic  flush),  the  eyes  bright,  and  the  pulse  quickened; 
during  the  night  the  temperature  falls  rapidly  with  profuse  sweating 
{night  sweat) ;  and  the  patient  soon  becomes  weak  and  emaciated. 

Amyloid  disease  {albuminoid,  lardaceoiis,  waxy,  or  colloid  degenera- 
tion) finally  supervenes.  The  cause  of  this  condition  is  not  known; 
it  may  be  due  to  the  chronic  toxemia,  or  to  the  draining  of  alkaline 
salts  from  the  blood  by  the  discharge.  The  walls  of  the  capillaries 
and  arterioles  and  eventually  the  viscera,  especially  the  spleen, 
liver,  and  kidneys,  become  infiltrated  with  an  albuminoid  or  waxy 
material.  The  mucous  membranes,  particularly  those  of  the  intes- 
tines, likewise  are  frequently  involved.  The  affected  organ  is  large, 
pale,  heavy,  and  smooth.  Owing  to  the  changes  in  the  intestinal 
mucosa,  disorders  of  digestion  and  diarrhea  are  present.  The  ca- 
chexia is  due  partly  to  the  prolonged  suppuration  and  partly  to  the  vis- 
ceral changes.  The  diagnosis  is  easily  made,  when  in  the  course 
of  a  prolonged  suppuration,  the  spleen  and  fiver  enlarge,  and  there  is 
diarrhea  and  polyuria,  with  albumin,  and  amyloid  casts  giving  the 
iodin  reaction.     The  time  necessary  for  the  production  of  amyloid 


114  MANUAL  OF  SURGERY 

disease  varies  within  wide  limits;  the  shortest  period  probably  being 
three  months.  Amyloid  disease  should  be  prevented  by  the  active 
treatment  of  chronic  suppuration.  Its  onset,  although  serious,  is 
an  indication  for,  rather  than  a  contraindication  to,  operation,  as 
the  process  may  be  checked  in  its  early  stages. 

The  diagnosis  of  a  cold  abscess  is  made  by  its  chronic  course, 
the  absence  of  inflammatory  symptoms  and  leukocytosis,  the  detec- 
tion of  changes  in  the  part  fiom  which  it  has  arisen  (e.g.,  bone,  joint, 
lymph  gland),  and  by  the  general  features  of  tuberculosis  (chap, 
xii).  In  doubtful  cases  aspiration  may  be  used.  A  tuberculous 
abscess  is  most  often  confused  with  a  lipoma,  a  cyst,  or  a  gumma,  less 
frequently  with  a  sarcoma,  hematoma,  hernia,  or  an  aneurysm.  A 
chronic  nontuberculous  abscess  may,  because  of  its  thick  walls,  be 
mistaken  for  a  solid  tumor. 

The  local  treatment  is  (i)  aspiration,  with  or  without  injections, 
(2)  incision.  (3)  excison. 

(i)  Simple  aspiration  and  aspiration  followed  by  irrigation  with  a 
weak  antiseptic  solution  are  occasionally  successful.  Iodoform 
emulsion  (10  per  cent,  in  glycerin  or  olive  oil)  may  be  injected,  after 
tapping  and  irrigation,  once  a  week  until  healing  occurs.  Not  more 
than  4  to  5  drams  should  be  used  in  an  adult,  and  not  more  than  2  or 
3  drams  in  a  child,  because  of  the  danger  of  poisoning.  Ethereal 
emulsions  become  gaseous  after  injection,  and  in  certain  regions  may 
produce  harmful  pressure.  Bier  makes  a  small  incision  and  applies 
a  vacuum  pump.  Beck  evacuates  the  pus  through  a  small  opening, 
and  fills  the  cavity  with  bismuth  paste  (see  "Sinus").  If  the  fluid 
reaccumulates,  the  abscess  is  reopened  and  the  fluid  allowed  to 
escape;  the  injection  is  not  repeated.  (2)  Incision  and  drainage, 
if  the  abscess  is  large,  is  so  often  followed  by  chronic  septic  intoxi- 
cation from  the  entrance  of  pyogenic  organisms  during  the  subsequent 
dressings,  that  the  ca\aty  should  never  be  left  open  if  it  can  be  closed 
with  safety.  Excluding  the  well  localized  superficial  abscess,  which 
may  be  treated  as  an  ordinary  acute  abscess,  incision  may  be  indicated 
under  the  following  circumstances,  fa)  If  the  contents  are  too  thick 
for  aspiration  the  abscess  may  be  opened,  the  granulations  curetted 
away,  the  cavity  irrigated,  iodoform  emulsion  introduced,  and  the 
wound  sutured,  (b)  If  the  cause,  e.g.,  diseased  bone  or  lymph 
glands,  can  be  removed  without  too  much  risk,  such  should  be  done. 
In  some  of  these  cases  it  will  be  necessary  to  pack  the  wound  with 
iodoform  gauze.  If,  with  the  purpose  of  eradicating  the  primary 
focus  in  view,  it  is  found,  on  exploration,  that  the  limits  of  the  abscess 
cannot  be  reached  or  the  cause  removed,  the  treatment  should  be 


SUPPURATION  115 

that  (lescribed  under  "a."  (c)  If  there  are  (hmgerous  pressure 
symptoms,  as  in  retropharyngeal  abscess,  drainage  must  be  insti- 
tuted, (d)  If  there  is  mixed  infection,  or  (e)  if  the  abscess  is  about 
to  evacuate  itself,  incision  is  indicated,  in  the  former  instance  curet- 
tage is  dangerous,  in  the  latter  the  thin  bluish  film  of  skin  at  the  site 
of  the  pointing  should  be  excised.  (3)  In  cases  in  which  the  abscess 
is  small,  particularly  when  connected  with  a  lymphatic  gland, 
excision  of  the  whole  abscess  cavity  and  suture  of  the  wound  is 
indicated.  It  may  be  necessary  to  adjust  apparatus  to  provide 
support  or  fixation  if  the  abscess  proceeds  from  bones  or  joints.  The 
constitutional  treatment  is  that  of  tuberculosis  (q.v). 

Abscesses  in  various  parts  of  the  body  which  require  special  men- 
tion will  be  found  in  those  sections  devoted  to  regional  surgery. 


CHAPTER  VIII 
ULCERATION 

Ulceration  is  the  progressive  molecular  destruction  of  super- 
ficial tissues.     Ulceration  of  bone  is  called  caries. 

The  cause  of  ulceration  is  infection,  or  lowered  resistance  of  the 
tissues  with  infection.  From  an  etiologic  standpoint  ulcers  may  be 
grouped  under  the  following  headings: 

1.  Simple,  or  better,  pyogenic  ulcers  include  those  in  which  the 
molecular  destruction  is  due,  wholly  or  principally  to  pyogenic 
organisms,  the  lower  resistance  of  the  tissues  being  the  result  of 
inflammation;  traumatism  (mechanical,  chemical,  thermal);  deficient 
circulation,  such  as  is  caused  by  scars,  atheroma,  the  lodging  of  an 
embolus,  pressure  (splint  sores  and  bed  sores),  and  passive  conges- 
tion (varicose  ulcer) ;  nervous  lesions  (corneal  ulcer  following  removal 
of  the  Gasserian  ganglion,  perforating  ulcer  of  the  sole  in  locomotor 
ataxia);  or  constitutional  diseases,  such  as  gout,  scurvy,  diabetes, 
and  mercuriahsm. 

2.  Ulcers  due  to  specific  bacteria  occur  in  chancroid,  tuberculosis, 
syphilis,  leprosy,  glanders,  anthrax,  and  other  conditions. 

3.  Malignant  ulcers  are  caused  by  the  breaking  down  of  malig- 
nant growths.  In  groups  two  and  three  infection  with  pyogenic 
bacteria  is  inevitable,  and  augments  the  destructive  process. 

Pathologically  a  spreading  ulcer  of  the  simple  type  presents  the 
changes  which  are  found  in  the  wall  of  a  spreading  abscess.  Ordi- 
narily an  abscess  ceases  to  extend  when  efficient  drainage  has  been 
established,  but  an  ulcer,  owing  to  the  virulency  of  the  infection  or 
the  feebleness  of  the  defensive  powers  of  the  tissues,  continues  to 
progress  despite  free  drainage.  In  addition  to  the  microscopic  cellu- 
lar disintegration,  which  results  in  the  formation  of  the  purulent 
discharge,  not  infrequently  dead  pieces  of  tissue  (sloughs),  visible 
to  the  unaided  eye,  are  cast  off,  after  being  set  free  by  the  suppura- 
tive process.  When  the  ulcer  spreads  with  great  rapidity  the  con- 
dition is  called  phagedena;  it  is  occasionally  seen  in  syphilis,  in  fact 
in  any  ulcer,  but  occurs  most  frequently  in  connection  with  chan- 
croid, and  was  at  one  time  common  as  hospital  gangrene.  As  an 
ulcer  deepens  contiguous  structures  may  be  involved,  e.g.,  a  leg 
ulcer  may  result  in  periostitis,  caries,  or  necrosis  of  the  tibia;  occa- 

116 


ULCERATION  II7 

sionally  large  blood  vessels  are  opened,  and  ulcers  in  the  gastroin- 
testinal canal  may  perforate  and  cause  generalized  peritonitis. 
Lymphangitis  and  lymphadenitis  occur  when  there  is  active  absorp- 
tion of  the  bacteria  or  their  products.  When  the  acute  inflammation 
about  an  ulcer  subsides  and  active  destruction  of  tissue  ceases,  the 
ulcer  either  becomes  chronic  or  passes  into  the  healing  stage.  An 
ulcer  may  fail  to  heal  because  of  persistent  or  repeated  infection, 
continued  irritation  (e.g.,  from  an  ingrowing  toe  nail),  want  of  rest 
(e.g.  ulcer  of  the  anus,  lip,  or  duodenum),  adhesion  to  deeper 
structures,  inversion  of  the  epithelial  edges,  exuberant  granulations, 
defective  nutrition  (e.g.  varicose  ulcer),  epitheliomatous  degenera- 
tion, or  a  general  state  of  depraved  vitality.  The  microscopic 
appearance  of  a  healing  ulcer  is  that  of  a  heahng  abscess  or  that  of  a 
wound  undergoing  repair  by  second  intention.  So  long  as  an  ulcer 
is  open  there  is  the  possibility  of  secondary  infection;  the  most  fre- 
quent comphcation  of  this  nature  is  erysipelas. 

The  diagnostic  considerations  may  be  listed  as  follows: 

1.  A  III  story  of  exposure  to  a  specific  form  of  infection  may  be 
obtained,  e.g.  chancre,  chancroids,  anthrax,  glanders,  or  to  a  par- 
ticular form  of  irritation,  e.g.,  in  those  who  work  in  acids. 

2.  The  period  of  incubation  is  of  particular  significance  in  chancre 
and  chancroid. 

3.  Mode  of  Onset. — An  injury  may  inaugurate  many  forms  of 
ulceration  besides  the  traumatic,  e.g.,  tuberculous,  syphilitic,  vari- 
cose, etc.  An  ulcer  due  to  an  embolus  is  preceded  by  a  small  area 
of  gangrene.  Pressure  ulcers  are  found  after  the  removal  of  splints 
and  apparatus.  An  ulcer  which  has  been  preceded  by  a  swelling 
may  be  the  result  of  inflammation,  tuberculous  abscess,  gumma,  or  a 
breaking  down  neoplasm.  Ulcers  following  a  rat  bite  or  a  thorn 
wound  should  make  one  suspect  sporotrichosis. 

4.  Duration. — Traumatic  ulcers  are  acute;  malignant  ulcers  may 
last  months,  varicose  ulcers,  years.  In  any  ulcer,  regarded  as  simple, 
that  persists  in  spite  of  treatment  the  possibility  of  epithelioma  should 
be  kept  in  mind. 

5.  A  number  of  ulcers  scattered  over  the  body  commonly  indicates 
some  general  disease,  although  chancroids  (local  infection)  are 
multiple  and  chancre  (constitutional  disease)  is  single. 

6.  Pain. — The  perforating  ulcer  of  the  sole  of  the  foot  and  other 
trophic  ulcers  may  be  painless;  acute  ulcers  in  healthy  tissue  are 
accompanied  by  a  burning  or  stinging  pain.  Intense  pain  with- 
out inflammation  is  experienced  in  the  erethistic,  irritable,  or  neural- 
gic ulcer. 


ii8 


MANUAL  OF  SURGERY 


B 


7.  5^2^.— Bed  sores,  varicose,  phagedenic,  and  malignant  ulcers 
may  attain  a  large  size.  The  ordinary  traumatic,  trophic,  and 
syphilitic  ulcers  are  smaller. 

8.  Shape. — Syphihtic  ulcers  are  circular,  semi-lunar,  irregular,  or 
serpiginous,  and  often  punched  out  in  appearance.  Tuberculous 
ulcers  are  ovoid  or  ragged. 

9.  Situation. — Traumatic  ulcers  occur  in  regions  exposed  to  injury, 

such  as  the  shin  and  elbow.  Ulcers 
on  the  tips  of  the  fingers  and  toes  may 
be  due  to  defective  circulation. 
Tuberculous  ulcers  are  frequent 
about  the  mouth  and  in  the  vicinity 
of  lymph  glands  (neck,  axilla,  groin) 
and  joints;  syphilitic  ulcers  about  the 
genitals  and  in  the  neighborhood  of 
joints;  lupoid  ulcers  on  the  face;  carci- 
noma about  the  face,  mouth,  breast, 
rectum,  and  genitals;  scorbutic  ulcers 
on  the  gums;  and  varicose  ulcers  in 
the  lower  third  of  the  leg.  Special 
mention  should  be  made  of  the  fre- 
quency with  which  a  chancre  is  not 
recognized  when  in  an  unusual  situa- 
tion, e.g.,  when  on  the  lip  or  the  finger. 
10.  The  Floor. — Large,  pale, 
edematous  granulations  suggest 
tuberculosis  or  some  other  debiHtat- 
ing  malady;  in  many  of  these  cases 
will  be  found  a  sinus  leading  down  to 
necrotic  bone  or  caseating  glands.  A 
syphilitic  ulcer  may  show  the  charac- 
teristic, dirty  yellow,  tough  slough  of 
gummy  degeneration.  The  floor 
may  be  covered  with  soft  friable 
papillae  in  blastomycosis,  a  thick  crust  of  clotted  blood  in  scurvy,  a 
false  membrane  in  diphtheria,  a  f ungating  mass  in  carcinoma.  In 
some  cases  a  section  should  be  removed  for  microscopic  examination. 
The  student  is  advised  to  compare  the  features  (floor,  edges,  dis- 
charge) of  the  acute,  the  chronic,  and  the  heahng  ulcers,  which  are 
given  at  the  end  of  this  chapter. 

II.  Undermined  edges  are  seen  especially  in  syphilis  and  tuber- 
culosis; thick,  non-granulating,  everted  edges  in  carcinoma  (Fig.  59). 


Pig-  59- — Diagrammatic  profiles  of 
ulcers.  A ,  Acute;  B,  indolent;  C,  heal- 
ing; D.E.,  carcinomatous;/^,  syphilitic; 
G,  syphilitic  or  tuberculous. 


ULCERATION  II9 

12.  The  (/^5c//ar^e  may  be  fetid  in  any  ulcer,  from  contaminat'on 
with  sapro])hytes;  the  amount  is  usually  in  proportion  to  the  activity 
of  the  destructive  process.  In  a  gouty  ulcer  urate  of  soda  may  be 
detected;  in  actinomycosis  minute  yellow  granules  resembling  grains 
of  iodoform.  A  tendency  to  spontaneous  bleeding  occurs  in  scorbu- 
tic and  malignant  ulcers.  When  the  diagnosis  is  uncertain  the 
discharge  may  be  examined  bacteriologically. 

13.  The  surrounding  tissues  may  show  evidence  of  syphilis  or 
defective  circulation,  or  they  may  be  healthy.  In  malignant  ulcers 
the  surrounding  tissues  are  the  seat  of  a  neoplastic  infiltration;  loss  of 
sensation  and  hair,  and  a  shiny  appearance  indicate  trophic  changes. 

14.  The  adjacent  lymph  glands  may  be  enlarged  in  any  form  of 
ulceration,  from  the  absorption  of  bacterial  products.  In  ordinary 
pyogenic  ulcers  they  show  the  signs  of  acute  inflammation.  In 
early  syphihs  the  enlargement  is  general,  and  the  glands  are  discrete 
and  do  not  mat  together;  in  carcinoma  they  enlarge,  infiltrate  the 
surrounding  tissues,  and  are  often  of  stony  hardness;  in  tuberculosis 
they  mat  together,  become  adherent  to  the  skin,  form  sinuses  which 
discharge  caseous  pus,  and  are  often  painless. 

15.  Age. — Ulcers  in  children  are  often  tuberculous  or  due  to 
congenital  syphihs;  in  old  age  varicose  and  malignant  ulcers  are 
more  common. 

16.  General  Condition  of  the  Patient. — Examine  for  tuberculosis, 
syphihs,  gout,  scurvy,  diabetes,  nephritis,  cardiac  disease,  and  for 
any  cause  that  impairs  the  general  health. 

17.  The  Wassermann  test  is  indicated  in  suspected  syphilis;  the 
tuberculin  tests  are  much  less  important. 

The  treatment  of  simple  ulceration  may  be  understood  more 
readily  if  the  principles  involved  are  first  enumerated,  and  then  their 
appUcation  pointed  out  with  the  description  of  the  three  clinical 
varieties  of  this  affection.     The  local  treatment  is  as  follows: 

I.  Removal  of  the  cause,  when  possible,  converts  the  ulcer  into  a 
heahng  wound.  Varicose  veins  my  be  removed  or  supported,  an 
ingrowing  toe  nail  excised,  and  jagged  teeth  extracted. 

2.  Rest  is  as  important  here  as  in  inflammation.  In  an  ulcer  of 
the  cornea  rest  is  secured  by  bandages  or  dark  glasses,  in  an  ulcer  of 
the  stomach  by  rectal  feeding  or  gastroenterostomy,  in  an  ulcer  of 
the  anus  by  dilatation  or  division  of  the  sphincter,  and  in  some  other 
regions  by  placing  the  patient  in  bed  or  by  the  use  of  splints. 

3.  Disinfection  of  the  skin  around  the  ulcer  may  be  effected  by 
shaving  if  there  is  much  hair,  and  then  applying  iodin,  or  with  soap 
and  water,  alcohol,  and  bichloride  of  mercury  solution.     Cleansing 


I20  MANUAL  OF  SURGERY 

the  ulcer  mechanically  by  spraying  with  hydrogen  peroxid  (half 
strength)  and  irrigating  with  salt  solution  is,  as  a  rule,  preferable  to 
the  use  of  strong  antiseptics,  which,  unless  concentrated  enough 
to  destroy  the  tissue  cells,  are  incapable  of  reaching  the  bacteria  in 
these  cells.  In  cases  of  very  active  ulceration,  however,  the  tissue 
cells  must  be  sacrificed  in  order  to  overcome  the  infection.  This  is 
notably  true  in  phagedena,  which  requires  for  its  conquest  very  power- 
ful disinfectants,  such  as  the  actual  cautery,  pure  carbolid  acid,  or 
nitric  acid.  Sloughing  is  best  treated  by  hot  fomentations  of  salt 
solution  or,  if  there  is  much  odor,  permanganate  of  potassium,  the 
loose  portions  of  the  slough  being  clipped  off  with  scissors  at  each 
dressing.  Dakin's  solution  and  dichloramin-T  also  are  of  value  in 
this  condition.  The  gauze  that  is  used  to  protect  the  ulcer  and  absorb 
the  discharges  may  be  moist  (salt  solution,  boracic  acid  solution)  or 
dry,  according  to  the  condition  of  the  granulations. 

4.  Compression  may  be  applied  to  the  margins  of  the  ulcer  to 
assist  in  the  absorption  of  exudate,  or  to  the  entire  limb  in  order  to 
prevent  or  to  overcome  congestion  and  edema  (vide  infra).  Mas- 
sage, which  is  a  form  of  intermittent  compression,  also  may  be  used 
for  the  latter  purpose. 

5.  Elevation  likewise  diminishes  the  amount  of  blood  in  the  part, 
and  is  indicated  in  all  forms  of  ulceration  in  which  it  may  be  secured; 
even  in  those  due  to  defective  arterial  circulation  the  tissues  are  apt 
to  be  filled  with  fluid. 

6.  The  granulations  may  be  deficient  or  exuberant.  Deficient 
granulations  may  be  stimulated  by  mildly  irritating  applications,  e.g. 
silver  nitrate  (gr.  10  to  the  oz.),  copper  sulphate  (gr.  10  to  the  oz.), 
balsam  of  Peru,  red  wash  (zinc  sulphate  gr.  2,  compound  tincture  of 
lavender  m.  10,  water  one  oz.  ),  argyrol  (10  per  cent.),  or  tincture  of 
iodin  (50  per  cent.).  Exuberant  granulations  (proud  flesh)  maybe 
removed  by  cauterizing  with  pure  nitrate  of  silver;  or  with  scissors,  a 
curette,  or,  in  order  not  to  devitalize  the  remaining  cells,  with  a  sharp 
knife  or  razor,  the  bleeding  being  controlled  by  pressure  with  dry 
gauze.  The  operation  is  painless,  since  the  granulations  contain 
no  nerve  filaments.  Edematous  granulations,  which  may  or  may  not 
be  exuberant,  require  the  treatment  just  indicated,  or  dry  dressings, 
exposure  to  the  air  and  sunshine,  or  electric  light  baths. 

7.  Epidermization  may  be  hastened  after  the  ulcer  has  begun 
to  heal,  by  skin  grafting;  or  by  scarlet  red  ointment  (8  per  cent,  in 
vaseline),  which  stimulates  epithelial  proliferation,  but  not  the 
granulations;  it  should  be  applied  to  the  epithelial  margins  only,  for 
24  hours  at  intervals  of  several  days,  and  not  continuously. 


ULCERATION  121 

8.  Incisions  radialinjz;  throuf^h  the  edji^es  of  the  ulcer,  or  curxx'd 
incisions  on  each  side  of  the  ulcer,  have  been  rec(jmniended  when 
healing  is  prevented  by  adhesions  to  the  underlying  structures. 

9.  Excision,  including  adjacent  cicatrcial  tissue,  may  be  advis- 
able under  similar  circumstances,  and  is  strongly  indicated  when  there 
is  a  menace  or  a  suspicion  of  malignancy.  Interference  with  cicatri- 
zation as  the  result  of  turning  in  of  the  edges  may  be  met  by  excising 
or  undercutting  the  edges. 

10.  Prevention  of  deformity  demands  that  the  part  be  placed  in 
the  best  position  to  oppose  the  contraction  of  the  scar  tissue  and 
that  the  scar  tissue  be  minimized  by  early  skin  grafting.  In  certain 
situations  (e.g.  esophagus,  urethra)  the  young  cicatrix  should  be 
stretched  by  the  passage  of  bougies,  in  order  to  anticipate  the  develop- 
ment of  a  tibrous  stricture. 

The  constitutional  treatment  is  that  of  sepsis  (q.v.),  or  of  any 
causative,  complicating,  or  independent  alTection  of  a  general 
nature. 

From  a  clinical  standpoint  a  simple  ulcer  may  be  regarded  as 
acute,  chronic,  or  healing. 

The  acute  ulcer  is  characterized  by  progressive  extension.  Its 
floor  is  covered  with  pus,  disintegrating  grayish  lymph,  dirty  yellow 
sloughs  of  variable  size,  and  no  granulations.  The  edges  are  eroded, 
thickened,  irregular  in  contour,  but  always  sharply  defined.  The 
discharge  is  profuse,  watery,  irritating,  occasionally  mixed  with 
blood.  The  surrounding  tissues  are  acutely  inflamed,  the  adjacent 
lymph  glands  enlarged  and  tender.  The  pain  is  often  burning  or 
stinging  in  character  and  may  be  severe.  The  constitutional  symp- 
toms are  those  of  sepsis. 

The  local  treatment  is  removal  of  the  cause,  rest,  disinfection,  and 
elevation,  as  pointed  out  above.  Powders  and  ointments  interfere 
with  free  drainage,  hence  are  contraindicated.  If  the  ulcer  is  on  a 
limb,  the  limb  should  be  bandaged  from  its  extremity  to  a  point 
above  the  ulcer.  The  management  of  lymphadenitis  is  given  on  a 
later  page.  When  the  ulcer  has  ceased  to  spread  and  the  granulations 
have  become  healthy  it  is  dealt  with  as  a  healing  ulcer.  The  general 
treatment  is  that  outlined  above. 

The  chronic  ulcer  is  most  frequently  seen  on  the  inner  side  of  the 
lower  third  of  the  leg,  in  the  latter  half  of  Hfe,  as  the  result  of  varicose 
veins  (varicose  ulcer),  but  is  encountered  also  in  other  regions,  espe- 
cially in  cicatrices,  notably  those  following,  extensive  burns  or 
burns  by  electricity,  radium,  or  the  X-ray.  Syphilis,  tuberculosis, 
indeed  any  debihtating  general  malady  predisposes  to  chronic  ulcera- 


122  MANUAL  OF  SURGERY 

tion.  In  the  viscera  chronic  indurated  ulcers  occur  most  often  in  the 
pylorus  and  the  duodenum.  Here  we  shall  confine  our  remarks  to 
the  varicose  variety  as  sufficiently  indicative  of  the  appearance  and 
the  treatment  of  chronic  ulcer.  The  ulcer  may  last  for  years  in  a 
stationary  condition  or  slowly  progress.  It  is  generally  oval  in 
shape.  The  floor  is  smooth,  glistening,  pale-red  or  dirty-yellow  in 
color,  and  presents  only  a  few  edematous  granulations  or  no  granu- 
lations. The  edges  may  be  flat,  but  are  more  often  humped-up,  hard, 
and  congested  {callous  ulcer).  The  discharge  varies  in  amount;  it 
may  be  thin,  seropurulent,  and  irritating,  or  thick,  fetid,  and  greenish 
in  color.  The  ulcer  is  frequently  attached  to  the  underlying  struc- 
tures (fascia,  bone),  so  that  contraction  is  prevented.  The  sur- 
rounding parts  are  often  edematous,  sometimes  with  an  overgrowth 
of  the  subcutaneous  tissues  resembling  elephantiasis.  The  skin  may 
be  pigmented,  owing  to  the  escape  and  disintegration  of  red  blood 
cells,  or  covered  with  eczema  {eczematous  ulcer).  Pain  is  usually 
slight  or  absent,  but  as  the  result  of  the  exposure  of  nerve  filaments, 
may  become  very  severe  {irritable,  erethistic,  neuralgic,  or  painful 
ulcer).  General  septic  manifestations  are  rare,  owing  to  the  absence 
of  acute  inflammation,  and  to  the  blocking  of  the  lymphatic  spaces 
by  organized  exudate. 

The  local  treatment  of  chronic  indolent  ulcers  is  frequently 
tedious  and  disappointing,  since  they  often  occur  in  patients  who 
cannot  afford  the  time  to  care  for  them  properly.  Varicose  veins 
should  be  removed  or  supported,  as  indicated  in  chap.  xv.  If 
possible,  rest  and  elevation  should  be  secured.  The  ulcer  may  be 
cleansed  as  described  above.  Compression  of  the  ulcer  alone 
may  be  obtained  by  overlapping  strips  of  adhesive  plaster,  which 
should  never  encircle  the  limb  for  more  than  two-thirds  of  its  circum- 
ference. A  piece  of  lint  the  exact  size  of  the  ulcer,  soaked  in  copper 
sulphate,  grains  lo  to  the  ounce,  is  first  placed  over  the  sore.  With 
this,  however,  should  always  be  combined  compression  of  the  whole 
leg  by  a  musKn  bandage  or  an  elastic  bandage  (flannel,  Martin's 
rubber  bandage,  Randolph  bandage).  The  Randolph  bandage 
consists  of  elastic  webbing  that  does  not  tend  to  macerate  the  skin 
like  the  rubber  bandage.  Unna's  paste  consists  of  gelatin  5  parts, 
oxid  of  zinc  5  parts,  boric  acid  i  part,  glycerin  8  parts,  and  water 
6  parts;  these  are  mixed  and  Hquefied  in  a  water  bath.  After 
cleansing  the  part,  a  gauze  bandage  is  applied  from  the  extremity 
of  the  limb  to  above  the  ulcer  and  painted  with  the  fluid;  several 
layers  of  gauze  may  thus  be  applied  and  painted.  The  liquid 
solidifies  on  cooling  and  resembles  adhesive  plaster,  so  that  most  of 


ULCERATION  1 23 

its  virtue  lies  in  the  compression  exerted;  this  dressing  may  be  left 
in  place  until  it  loosens  (one  to  three  weeks).  If  there  is  much 
discharge,  the  dressing  may  be  appKed  every  few  days,  or,  better, 
the  ulcer  itself  may  be  left  uncovered  for  drainage  and  cleansing. 
Schulze  purifies  the  ulcer  with  soap  and  water,  and  dresses  it  with  a 
solution  of  acetate  of  aluminium  (2  per  cent,  in  water)  until  the  dis- 
charge decreases  and  loses  its  odor;  a  piece  of  lint  the  size  of  the 
ulcer  is  then  soaked  in  spirits  of  camphor,  and  applied  beneath 
absorbent  cotton,  rubber  dam,  and  a  compression  bandage.  The 
camphor  is  reapplied  every  other  day,  after  washing  with  a  2  per  cent. 
solution  of  carbolic  acid.  Massage  of  the  whole  leg  is  frequently  of 
great  benefit.  The  remarks  previously  made  on  the  control  of  the 
granulations,  epidermization,  incisions,  and  excision  are  applicable 
to  varicose  ulcers.  An  irritable  ulcer  is  treated  by  cauterizing  or 
excising  the  painful  spot,  by  passing  a  tenotome  above  it  to  divide 
the  affected  nerve  filament,  or  by  curetting  the  whole  ulcer.  Ec- 
zema requires  cleansing  with  sweet  oil,  and  the  application  of  ichthyol 
(5-10  per  cent.),  lead-water  and  laudanum,  Unna's  dressing,  Hq. 
carbonis  detergens  (i  ounce  to  liq.  plumbi  subacetat.  dil  i  pint),  oxid 
of  zinc  ointment,  or  boracic  acid  ointment. 

General  treatment  should  be  directed  to  any  existing  constitu- 
tional disease.  Affections  of  the  heart,  the  arteries,  and  the  kidneys 
are  not  infrequently  present.  Strychnin,  digitalis,  and  nitroglycerin 
are  often  of  service. 

The  healing  ulcer  progressively  diminishes  in  size.  The  floor 
is  covered  with  firm,  bright  red  granulations.  The  edges  are  slop- 
ing, only  sHghtly  raised,  and  present  three  zones,  (i)  a  red  zone 
of  granulation  tissue,  (2)  a  blue  or  purpHsh  zone  of  beginning  epider- 
mization, (3)  a  white  zone  of  skin.  The  discharge  is  scanty,  serous, 
or  seropurulent.  The  surrounding  tissues  are  normal.  Pain  is 
usually  absent. 

The  local  treatment  is  rest,  cleanliness,  elevation,  prevention  of 
deformity.  The  granulations  may  be  protected  from  the  avulsing 
effect  of  dry  dressings  by  paraffined  gauze,  or  by  sHghtly  separated 
strips  of  rubber  tissue  or  silver  foil,  unless  these  are  found  to  produce 
maceration.  Ointments,  of  which  sterile  vaselin  is  perhaps  the  best, 
are  permissible  in  these  cases,  provided  the  hnt  on  which  they  are 
spread  is  sterile,  and  perforated  with  numerous  holes  for  the  purpose 
of  drainage.  Prolonged  appHcations  of  greasy  substances,  however, 
may  cause  the  granulations  to  become  flabby  and  edematous.  Lard 
as  an  ointment  base  should  never  be  employed,  as  it  quickly  putrefies. 
Powders  are  usually  contaminated  with  micro-organisms,  and  form  a 


124  MANUAL  OF  SURGERY 

crust  which  interferes  with  the  proper  toilet  of  the  part.     General 
treatment  may  possibly  be  needed  for  weakness  or  anemia. 

Specific  and  malignant  ulcers  and  ulcers  of  particular  regions, 
with  the  exception  of  varicose  ulcer,  which  has  just  been  described, 
are  considered  under  their  respective  headings  in  later  chapters. 

SINUS  AND  FISTULA 

A  sinus  is  an  abnormal  canal  leading  from  the  skin  or  the  mucous 
membrane  down  into  the  tissues;  it  is  lined  with  granulations, 
discharges  pus,  and  usually  ends  in  the  cavity  of  an  unhealed  abscess. 
Sinuses  are  caused  by  (i)  foreign  bodies,  either  exogenous  (e.g.,  a 
bullet,  needle,  or  non-absorbable  ligature),  or  endogenous,  e.g.,  a 
caseating  gland,  necrotic-bone,  or  carious  tooth ;  (2)  deficient  drainage, 
that  is,  the  orifice  heals,  pus  accumulates,  another  abscess  forms, 
spontaneous  evacuation  occurs,  and  the  process  is  repeated  over  and 
over;  (3)  want  of  rest;  (4)  infection  of  the  walls,  especially  by  the 
tubercle  bacillus;  (5)  ingrowth  of  epithelium;  (6)  fibrous  or  bony  rigid- 
ity of  the  walls,  which  prevents  their  coming  together;  and  (7)  general 
debility. 

The  diagnosis  is  seldom  difficult.  The  orifice  of  a  sinus  and  the 
discharge  can  almost  always  be  seen,  the  tract  can  often  be  felt  as  a 
cord-like  induration,  and  the  cause  is  frequently  revealed  by  the  his- 
tory and  the  X-ray.  Probing  may  be  necessary,  but  is  usually  inad- 
visable, because  it  may,  by  rubbing  off  the  granulations,  result  in 
absorption  of  bacterial  products,  causing  fever.  The  direction, 
length,  and  shape  of  the  tract,  and  the  presence  of  diverticula,  may 
be  shown  by  the  X-ray,  after  the  injection  of  bismuth  paste  or  other 
opaque  substance  (see  "Pyelography").  In  some  cases  the  discharge 
should  be  investigated  bacteriologically. 

The  treatment  is  removal  of  the  cause.  The  sinus  should  be 
opened,  explored,  disinfected,  and  loosely  packed  with  gauze,  so 
that  it  may  heal  from  the  bottom.  In  ligature  sinuses  the  ligature 
may  often  be  removed  by  fishing  with  a  crochet  needle.  In  some 
cases,  e.g.,  those  caused  by  rigid  walls  or  ingrowth  of  epithelium, 
excision  should  be  performed.  In  dissecting  out  a  small  or  tortuous 
sinus  the  tract  may  be  followed  with  greater  ease  if  it  is  injected 
with  a  colored  fluid  (methylene  blue,  briUiant  green,  collargol). 
In  tuberculous  sinuses  not  suited  for  radical  operation  Bier's 
suction  pump  or  the  injection  of  Beck's  bismuth  paste  may  be  tried. 
Two  preparations  of  bismuth  paste  are  used.  The  first  consists  of 
bismuth  subnitrate  $^  per  cent.,  and  vasehn  67  per  cent.,  the  second 


ULCERATIOX  1 25 

of  bismuth  subnitrate  30  per  cent.,  white  wax  5  per  cent.,  paraffin 
5  per  cent.  (120°  melting  point),  and  vaselin  60  per  cent.  The 
vaselin,  wax,  and  paraffin  are  sterilized  by  boiling,  and  the  l)ismuth 
stirred  in  after  the  mixture  has  been  removed  from  the  lire.  As  the 
bismuth  gravitates  to  the  bottom  the  mixture  should  be  heated  and 
stirred  before  using.  Care  should  be  taken  to  exclude  water,  as  it 
destroys  the  homogeneous  quality  of  the  mixture  and  interferes  with 
its  retention  in  the  sinus.  The  syringe  should  have  a  blunt  nozzle 
like  that  of  a  urethral  syringe.  The  mouth  of  the  sinus  is  sterilized 
with  alcohol,  the  nozzle  of  the  charged  syringe  pressed  against  it, 
and  the  injection  made  until  the  patient  complains  of  pressure. 
A  piece  of  gauze  is  then  pressed  against  the  opening  until  the 
paste  has  set;  an  ice  bag  will  hasten  this  process.  The  first  prepa- 
ration is  used  for  diagnosis  (by  taking  a  radiogram  after  the  injec- 
tion) and  during  the  early  part  of  the  treatment,  the  second  prepara- 
tion when  it  is  desired  to  retain  the  paste  in  the  sinus  and  when 
there  is  no  danger  of  damming  up  pus.  Healing  may  follow  a  single 
injection,  or  it  may  be  necessary  to  repeat  the  injection  once  a 
week.  The  bismuth,  w^hich  is  bactericidal  and  astringent,  is  absorbed 
and  replaced  by  fibrous  tissue.  If  septic  symptoms  supervene  the 
bismuth  may  be  dissolved  with  hot  olive  oil  and  withdrawn  with  a 
Bier  suction  pump.  More  than  100  grams  of  the  33  per  cent, 
paste  should  never  be  injected,  because  of  the  danger  of  bismuth 
poisoning  (stomatitis,  black  line  on  the  gums,  diarrhea,  cyanosis,  ne- 
phritis, emaciation).  According  to  Freilich  there  have  been  68 
cases  of  bismuth  poisoning  wath  26  fatalities  after  the  Beck  method. 
In  the  vicinity  of  large  veins  the  possibility  of  embolism  should  be 
kept  in  mind.  Xo  matter  what  local  treatment  is  adopted  constitu- 
tional diatheses  should  receive  proper  attention. 

A  fistula  is  an  abnormal  canal  between  two  anatomical  cavities 
(internal  fistula),  or  between  an  anatomical  cavity  or  a  gland  and 
the  surface  of  the  body  (external  fistula).  The  tract  is  lined  with 
epithelium,  endothelium,  or  granulations,  or  partly  with  epi-  or 
endothehum  and  partly  with  granulations,  and  discharges  the  con- 
tents of  the  cavity  or  the  secretion  of  the  gland  with  which  it  com- 
municates. Fistulse  are  the  result  of  (i)  developmental  defects, 
e.g.,  branchial  and  umbihcal  fistulae;  (2)  injuries,  e.g.,  aerial,  sali- 
vary, and  vesico-vaginal  fistulae;  (3)  disease,  e.g.,  urinary  and  anal 
fistulae;  and  (4)  purposive  operations,  e.g.,  gastric  and  biliary  fistulae. 
Each  of  these  wall  be  considered  in  its  appropriate  place. 


CHAPTER  IX 
GANGRENE 

Mortification,  or  gangrene,  is  death  of  all  the  tissues  composing  a 
portion  of  the  body,  e.g.,  the  leg.  Death  of  the  soft  parts  alone  is 
called  sloughing,  or  sphacelation,  and  the  dead  tissue  a  slough,  or 
sphacelus.  The  terms  gangrene  and  sloughing,  however,  are  often 
used  interchangeably,  and  the  term  necrosis,  which  means  any  form 
of  local  death.. is  usually  restricted  by  the  surgeon  to  indicate  the 
death  of  a  visible  portion  of  bone,  the  dead  mass  being  called  a 
sequestrum. 

The  signs  of  gangrene  are  (i)  loss  of  arterial  pulsation;  (2)  loss  of 
heat,  the  temperature  of  the  part  becoming  that  of  its  surroundings; 
(3)  loss  of  sensation,  a  dead  hmb  may,  however,  have  pain  or  sensa- 
tion referred  to  it,  just  as  a  patient  whose  arm  has  been  amputated 
may  feel  pain  in  his  fingers;  (4)  loss  of  function;  (5)  loss  of  natural 
color,  the  part  becoming  pale,  then  purplish  or  greenish  in  moist 
gangrene,  and  black  in  dry  gangrene. 

According  to  the  changes  which  ensue,  gangrene  is  divided  into 
two  forms,  the  dr\'  and  the  moist. 

Dry  gangrene  (mmnmijicatioii)  results  when  the  tissues  have  very 
little  fluid  in  them  at  the  time  of  death.  It  is  usually  but  not  in- 
variably due  to  gradual  cutting  off  of  the  arterial  supply,  hence  is 
generally  chronic.  The  fluid  in  the  tissues  evaporates,  the  part 
becoming  dry,  hard,  wrinkled,  shriveled,  and  finally  deep  black  in 
color  (Fig.  61).  The  tissues  above  the  area  of  gangrene  are  usually 
inflamed.  The  odor  is  slight  unless  putrefactive  organisms  are 
present. 

Moist  gangrene  (Fig.  62)  occurs  when  the  tissues  are  full  of  fluid 
at  the  time  of  their  death.  It  usually  follows  sudden  blocking  of  the 
arterial  supply  or  the  venous  return,  hence  is  practically  always 
acute.  There  is  great  swelhng,  the  formation  of  blebs,  and  loosening 
of  the  whole  epidermis.  Owing  to  putrefaction  the  color  changes 
from  white  to  purple,  and  finally  to  greenish  or  blackish,  and  the 
tissues  become  soft,  fetid,  and  sometimes  contain  gas.  Aseptic 
moist  gangrene,  in  which  putrefaction  is  absent,  is  rarely  seen  by  the 
surgeon,  but  should  be  striven  for  by  strict  antisepsis,  when  it  is 

126 


GANGRENE  1 27 

known  that  a  part,  e.g.,  a  limb  after  ligation  of  the  main  artery,  is 
about  to  fall  into  moist  gangrene. 

Gangrene  terminates  in  (i)  death  of  the  individual,  or  (2)  in 
separation  of  the  dead  part  from  the  living.  In  the  internal  organs  a 
small  aseptic  area  of  gangrene  may  be  absorbed  or  encysted.  On  the 
surface,  or  in  the  internal  organs  if  the  process  be  septic,  separation 
takes  place  by  ulceration,  the  line  between  the  living  and  dead 
tissues  being  called  the  li)ic  of  demarcation. 

According  to  etiology  gangrene  may  be  classified  into  three 
groups:  (i)  Indirect  gangrene,  which  is  caused  by  interference  with 
the  blood  supply,  and  in  which  the  general  condition  of  the  patient  is 
usually  an  important  factor,  includes  (a)  senile,  (b)  pre-senile, 
(c)  diabetic,  (d)  post-febrile,  (e)  Raynaud's,  (f)  ergot  gangrene, 
(g)  ainhum,  (h)  gangrene  from  embolus,  (i)  ligature  of  the 
principal  artery  of  a  limb,  (j)  thrombosis  of  an  artery  the  result 
of  injury,  and  (k)  obstruction  of  the  principal  artery  and  vein;  (2) 
direct  gangrene,  the  result  of  direct  trauma  to  the  tissues,  includes 
gangrene  from  (a)  severe  crushes,  (b)  prolonged  pressure,  (c)  chemical 
injuries,  (d)  the  X-ray,  (e)  frost  bites,  and  (f)  burns  and  scalds; 
(3)  Mixed  or  microbic  gangrene,  in  w^hich  the  tissue  cells  are  directly 
killed  by  bacterial  toxins  and  the  blood  vessels  occluded  by  thrombo- 
sis, includes  (a)  gas  gangrene,  (b)  hospital  gangrene,  and  (c)  noma. 

(i)  INDIRECT  GANGRENE 

(a)  Senile  gangrene  is  the  result  of  obliterating  endarteritis,  and 
occurs  in  the  old,  in  whom  the  heart  is  generally  feeble  and  the  kid- 
neys diseased,  thus  contributing  to  the  impairment  of  nutrition. 
It  is  most  frequent  in  the  lower  extremity,  but  occasionally  attacks 
the  upper  extremity  or  even  the  nose  and  ears.  The  arteries  become 
calcareous,  much  reduced  in  calibre,  and  inelastic.  The  actual  onset 
of  gangrene  is  often  determined  by  a  slight  injury  or  inflammation, 
which  induces  thrombosis  in  the  smaller  vessels;  or  a  thrombus  may 
form  in  the  artery  supplying  the  part. 

The  prodromal  symptoms  are  coldness,  numbness,  tingling  or 
cramp-like  pains,  and  sometimes  intermittent  claudication.  The 
leg  Tthe  part  usually  affected)  is  congested,  the  color  returns  slowly 
after  digital  pressure  and  the  pulse  at  the  ankle  is  very  faint.  The 
gangrene  starts  as  a  httle  area  of  inflammation,  which  usually  ulcerates 
and  then  dries,  forming  a  black  slough,  which  gradually  spreads  into 
the  adjacent  tissues  and  assumes  the  characteristics  mentioned  under 
dry  gangrene.     The  surrounding  tissues  are  inflamed,   the  redness 


128  MANUAL  OF  SURGERY 

becoming  purple,  and  finally  black  as  the  process  advances.  When 
tissues  are  reached  in  which  the  blood  supply  is  sufificiently  active  to 
prevent  thrombosis,  a  line  of  demarcation  forms.  Occasionally  a 
spurious  hne  of  demarcation  will  begin  to  form,  but  the  gangrene 
advances  beyond  it.  Severe  pain  and  marked  exhaustion  are  often 
present,  and  if  infection  occurs,  a  fetid  odor  arises  and  symptoms  of 
sepsis  supervene.  Death  occurs  from  exhaustion,  septic  absorption, 
or  from  complicating  cardiac,  pulmonary,  or  renal  disease. 

The  prophylactic  treatment  in  those  who  exhibit  prodromal 
symptoms  consists  in  avoidance  of  injury,  careful  attention  to  the 
slightest  bruise  or  cut.  cardiac  stimulants,  nitroglycerin,  massage,  and 
keeping  the  feet  warm  with  woolen  stockings  in  the  day  time  and  a 
warm  water  bag  at  night.  The  treatment  of  the  gangrene  itself 
depends  upon  its  extent  and  the  general  condition  of  the  patient. 
If  but  one  or  two  toes  are  affected  and  the  general  health  good, 
one  should  wait  for  a  line  of  demarcation,  in  the  meantime  keeping 
the  foot  dry,  warm,  elevated  and  antiseptic.  In  order  to  prevent 
the  spread  of  the  gangrene,  an  anastomosis  between  the  femoral 
artery  and  vein,  to  permit  the  veins  to  carry  blood  to  the  under-nour- 
ished tissues,  has  been  tried  in  a  few  cases,  without,  however,  encourag- 
ing results.  When  the  line  of  demarcation  forms,  the  casting  off  process 
may  be  assisted  by  scissors,  and  the  remaining  ulcer  treated  antisep- 
tically,  or  a  formal  amputation  may  be  performed.  If  the  gangrene 
spreads  to  the  foot  or  higher,  if  symptoms  of  sepsis  arise,  or  if  the 
general  condition  of  the  patient  is  such  that  he  will  not  withstand  the 
tedious  efforts  of  nature  to  rid  him  of  the  gangrenous  part,  immediate 
amputation  should  be  performed  through  the  lower  third  of  the 
thigh,  as  at  any  lower  point  recurrence  of  the  gangrene  is  almost 
certain  to  follow.  The  deep  femoral  artery,  which  helps  to  nourish 
the  flaps  after  amputation  through  the  lower  thigh,  rarely  becomes 
atheromatous.  The  tissues  should  be  bruised  as  little  as  possible,  the 
flaps  made  of  the  same  length,  so  that  they  will  be  well  supplied  with 
blood,  and  the  Esmarch  band  omitted,  as  it  favors  the  formation  of  a 
thrombus  in  the  femoral  artery.  This  disadvantage  of  elastic  con- 
striction contraindicates  also  the  Mosckcowitz  test  for  determining  in 
advance  the  probable  hne  of  demarcation  (see  "Amputations," 
chap.  xxxi). 

(b)  Presenile  gangrene,  called  thromboangitis  obhterans  by 
Buerger,  is  the  same  as  senile  gangrene,  except  that  it  attacks  the 
young.  It  is  more  frequent  in  Hebrews  and  is  sometimes  confused 
with  Raynaud's  gangrene.  The  treatment  is  that  of  senile  gangrene. 
The  cause  of  the  arteritis,  if  ascertainable,  also  should  be  combated. 


GANGRENE  I 29 

(c)  Diabetic  gangrene  likewise  is,  in  most  instances,  due  to  an 
obliterating  endarteritis.  Sugar  in  the  blood  lessens  the  resistance 
of  the  tissues  and  acts  as  a  contributing  factor.  Some  believe  the 
cause  to  be  a  peripheral  neuritis.  The  gangrene  is  apt  to  be 
inaugurated  by  a  slight  wound,  which  becomes  infected  and  necrotic, 
the  process  extending  and  involving  the  whole  limb;  it  may  occur  in 
any  portion  of  the  body,  but  is  most  frequent  in  the  lower  extremity,  in 
the  latter  half  of  life.  It  may  be  dry  if  the  arterial  disease  is  far  ad- 
vanced, but  is  much  more  likely  to  be  of  the  moist  variety,  and  is 
then  often  very  rapid  in  its  progress.  The  treatment  is  that  of  senile 
gangrene.  Even  after  high  amputation  the  ilaps  are  apt  to  become 
gangrenous,  and  many  cases  die  in  diabetic  coma  after  operation. 
Increased  blood  sugar  content;  albuminuria,  the  presence  of  ace- 
tone, diacetic,  or  oxybutyric  acid  in  the  urine,  or  an  increase  in  the 
amount  of  ammonia  excreted,  makes  the  prognosis  particularly 
unfavorable.  The  symptoms  and  treatment  of  acidosis  or  aceto- 
nuria,  are  given  under  delayed  chloroform  poisoning  (see  "Anes- 
thesia"). In  order  to  prevent  acidosis  the  patient  should  not  be 
restricted  to  a  diabetic  diet  at  once,  but  gradually,  and  if  acetone 
or  diacetic  acid  appears  in  the  urine,  the  amount  of  sugar  in  the  diet 
should  be  increased  and  sodium  bicarbonate  administered.  A  local 
anesthetic  may  be  employed  to  lessen  the  danger;  if  a  general  anes- 
thetic is  used,  nitrous  oxid  and  oxygen  is  the  safest;  chloroform  is 
absolutely  contraindicated. 

(d)  Post-febrile  gangrene  may  occur  during  the  convalescence 
from  any  fever,  especially  those  of  long  duration  like  typhoid.  It 
may  be  dry  or  moist,  and  is  due  to  arteriothrombosis  the  result  of 
endarteritis,  or  to  the  lodging  of  an  embolus.  The  occurrence  of 
gangrene  of  an  extremity  from  phlebitis  alone  is  doubtful.  The 
treatment  is  that  of  senile  gangrene. 

(e)  Raynaud's,  or  symmetrical  gangrene,  is  a  form  of  dry  gangrene 
occurring  in  Raynaud's  disease,  which  is  a  vaso-motor  neurosis  most 
frequently  found  in  young,  anemic,  hysterical  females.  The  cause 
probably  lies  in  the  vaso-motor  centers.  It  usually  attacks  the 
fingers  or  toes,  occasionally  other  parts  of  the  body,  and  sometimes 
follows  exposure  to  cold,  sometimes  emotional  disturbances.  Hemo- 
globinuria and  scleroderma  occur  in  some  cases.  There  are  three 
stages:  (i)  The  parts  become  white,  stiff,  and  painful  (local  syncope), 
owing  to  spasm  of  the  arterioles;  then  (2)  cold,  blue,  and  congested 
(local  asphyxia) ;  or  if  the  attack  terminates  in  this  stage,  red,  hot, 
and  swollen;  and  finally  in  unfavorable  cases  (3)  dry,  black,  and  anes- 
thetic (gangrene),  as  the  result  of  thromboarteritis.     The  process 


I30 


MANUAL  OF  SURGERY 


usually  remains  superficial,  although  a  phalanx  may  become  necrotic. 
The  treatment  is  that  of  senile  gangrene,  and  attention  to  the  asso- 
ciated neurosis.  Thyroid  extract  is  occasionally  beneficial.  In  the 
first  stage  an  Esmarch  band  may  be  applied  above  the  aftected  part 
for  several  minutes;  when  it  is  removed  blood  rushes  into  the  paretic 
vessels. 

(f)  Ergot  gangrene  is  very  rare  at  the  present  time.  It  is  due  to  a 
spasmodic  contraction  of  the  arterioles,  from  eating  bread  made  with 
diseased  rye.  The  gangrene  is  dry  and  superficial,  but  may  spread 
rapidly  and  involve  an  entire  Limb,  especially  if  there  is  associated 
arteriosclerosis  and  infection.  The  fingers  and  toes  are  the  parts 
most  often  aft'ected.  The  treatment  is  that  of  senile  gangrene,  with 
measures  for  promoting  the  elimination  of  the  ergot. 


Fig.  6o. — Ainhum. 


(g)  Ainhum  (Fig.  60)  is  a  peculiar  trophic  lesion  aft'ecting  the 
little  toe,  rarely  the  other  toes  or  the  fingers.  It  almost  always 
attacks  negroes  and  is  confined  to  tropical  and  subtropical  countries. 
A  furrow  of  callous  tissue  forms  around  the  base  of  the  toe  and 
slowly  deepens  until  the  toe  falls  oft*.  Division  or  excision  of  this 
furrow  may  be  of  service,  but  amputation  is  the  usual  result. 

(h)  Gangrene  from  Embolus.- — In  the  lower  extremity  an  embolus 
usually  lodges  at  the  bifurcation  of  the  femoral  or  the  popHteal.  in  the 
upper  extremity  at  the  point  where  the  superior  profunda  is  given  oft" 
or  at  the  bifurcation  of  the  brachial.  As  ligature  of  the  main  artery 
of  a  hmb  is  usually  insufficient  of  itself  to  cause  gangrene,  so  with  the 
lodgment  of  an  embolus;  the  collateral  circulation  is  likely  to  be 


GANGRENE  I3I 

established  unless  there  be  a  previous  diminution  in  the  vitality  of 
the  part,  e.g.,  from  cardiac  disease,  endarteritis,  or  an  associated 
general  disease.  The  symptoms  and  general  facts  of  embolism  are 
given  in  chap.  xv.  Owing  to  the  sudden  cutting  off  of  blood  pres- 
sure, venous  blood  surges  back  into  the  limb,  which  becomes  bluish, 
swollen,  edematous,  and  llnally  the  seat  of  moist  gangrene.  Dry 
gangrene  (Fig.  61),  however,  occasionally  follows,  particularly  if  there 
has  been  previous  chronic  malnutrition  of  the  limb  the  result  of 
endarteritis.  The  treatment  is  that  of  senile  gangrene.  In  order  to 
prevent  or  to  limit  embolic  gangrene  we  have  in  three  cases  incised 
the  artery  (two  femoral,  one  abdominal  aorta)  and  removed  the 
embolus,  subsequently  suturing  the  wound  in  the  vessel. 


Pig.  61. — Dry  gangrene  from  embolus. 

(i)  Gangrene  from  ligature  of  theprincipalartery  of  alimb  seldom 
occurs  if  the  general  health  is  unimpaired  and  the  limb  sound.  The 
same  general  facts  apply  here  as  in  gangrene  from  embolus.  Except 
in  emergency  cases  it  is  a  good  plan  to  compress  the  artery  at  inter- 
vals for  several  days  before  ligation,  in  order  to  encourage  the  forma- 
tion of  an  efficient  collateral  circulation.  In  many  instances  there  is 
a  loss  of  one  or  two  toes,  the  result  of  dry  gangrene.  The  treatment 
is  that  of  senile  gangrene. 

(j)  Gangrene  from  thrombosis  of  an  artery  the  result  of  injury  oc- 
casionally occurs,  the  symptoms  and  treatment  being  practically 
identical  with  those  of  embolic  gangrene.  Lejars  and  the  author 
have  each  opened  the  femoral  artery,  removed  a  thrombus,  and  then 
sutured  the  vessel.  In  each  case  the  thrombosis  recurred  and  the 
hmb  was  amputated  for  gangrene. 

(k)  Obstruction  of  the  principal  artery  and  vein,  the  result  of 


132  MANUAL  OF  SURGERY 

ligature  or  injury,  is  almost  sure  to  be  followed  by  gangrene.  This 
is  the  form  of  gangrene  which  occurs  in  strangulated  hernia  and  in  a 
limb  which  is  tightly  constricted  by  bandages.  When  a  large  artery 
has  been  wounded,  the  venae  comites  may  be  obstructed  by  the 
extravasated  blood.  The  gangrene  is  of  the  moist  variety.  The 
treatment  in  cases  complicated  by  serious  crushing  of  the  surrounding 
parts  is  immediate  amputation;  in  other  cases  one  should  wait  for  a 
line  of  demarcation,  unless  the  occurrence  of  sepsis  prevents  such  a 
course. 

(2)  DIRECT  GANGRENE 

(a)  Severe  crushes  fFig.  62),  such  as  are  produced  by  machinery 

and  railroad  accidents,  may 
directly  destroy  the  tissues, 
which  if  allowed  to  remain, 
putrefy,  the  gangrene  being  of 
the  moist  variety.  The  treat- 
ment is  immediate  amputation 
(^see  "Amputations"). 

(b)  Gangrene  from  pro- 
longed pressure  is  seen  princi- 
pally in  bed  sores  and  after  the 
use  of  improperly  applied 
splints.  The  so-called  trophic 
t^'t/ngr^^^e  usually  occurs  in  parts 
H  which  have  been   deprived   of 

W"  sensation,  and  in  these  cases  is 

the  result  of  pressure  or  irrita- 

FiG.   6..--Mo:.t  gangrene  from  injury.  ^-^^^  ^^^^^^  continues  simply  be- 

cause the  patient  does  not  know  of  its  existence;  vaso-motor  paresis 
is  a  secondary  factor.  Gangrene,  the  result  of  pressure  from  splints, 
bandages,  or  apparatus,  is  generally  the  result  of  carelessness,  but 
occasionally  occurs  when  such  accusation  cannot  be  made  with 
justice,  for  instance,  in  an  old  person  with  badly  diseased  arteries,  or 
in  a  limb  in  which  the  vessels  have  been  occluded  by  an  injury. 
In  all  injuries  one  should  examine  the  vessels  before  applying  a 
sphnt  or  a  bandage.  The  gangrene  is  generally  superficial  (slough), 
but  may  extend  deeply  and  widely  if  the  parts  become  septic.  The 
sloughs  are  allowed  to  separate  under  antiseptic  dressings,  and  the 
ulcer  is  skin  grafted  to  hasten  heaHng  and  prevent  contractures. 

Bed  sores  (decubitus,  decubital  gangrene)  are  the  result  of 
prolonged  pressure  on  tissues  whose  resistance  is  impaired,  usually 


Pig.  63. — Carbolic  acid  gangrene.  A  splinter  wound  01  the  finger  was  treated  by  the 
application  of  a  solution  of  carbolic  acid  of  unknown  strength  tor  five  hours,  at  the  end  of 
which  time  the  finger  was  cold,  white,  and  numb.     Amputation. 

(Facing  page  133) 


GANGRENE  133 

by  a  protracted  general  illness.  They  arc  most  apt  to  occur  over 
bony  prominences,  such  as  the  occiput,  scapulae,  elbows,  sacrum, 
trochanters  (Fig.  229),  and  heels.  At  first  the  part  becomes  red, 
and  in  the  center  of  the  red  area  appears  an  excoriation  or  small 
blister,  which  is  soon  rubbed  off;  the  resulting  ulcer  spreads  into  the 
surrounding  tissues,  or  a  large  slough  forms.  In  neglected  cases  or 
in  cases  in  which  there  is  impairment  of  sensation,  the  sore  rapidly 
increases  in  extent  and  depth,  and  may  involve  even  the  bone,  in 
which  event  exhaustion  and  death  may  follow  from  severe  pain  and 
septic  absorption,  or,  if  recovery  ensues,  healing  may  not  occur  for 
months  or  even  years.  In  disease  or  injury  of  the  nervous  system, 
especially  fractures  of  the  spine,  bed  sores  may  appear  within  a 
day  or  two  (acute  bed  sores).  The  prophylactic  treatment  consists  in 
changing  the  position  of  the  patient,  so  as  to  give  as  much  rest  as 
possible  to  the  parts  exposed  to  pressure,  and  the  use  of  circular  air 
cushions,  or  of  a  water  or  air  bed;  these  should  be  neither  too  full, 
which  makes  them  too  hard,  nor  too  empty,  which  allows  the  body 
to  rest  on  the  bed  supports.  Parts  exposed  to  pressure  should  be 
inspected  frequently,  and  the  circulation  maintained  by  rubbing 
with  salt  and  whisky  (a  tablespoonful  to  the  pint),  or  with  alum  and 
alcohol  (15  grains  to  the  pint),  followed  by  powdering  with  talcum, 
boric  acid,  or  stearate  of  zinc.  The  sheet  should  be  kept  clean  and 
smooth,  rough  handhng  avoided,  hot  water  bags,  if  used,  applied 
with  great  caution,  and  special  care  taken  that  no  particles  of  food 
find  their  way  beneath  the  patient.  If  the  sheet  becomes  soiled  with 
urine  or  feces,  or  wet  with  perspiration,  it  should  be  changed  at  once. 
If  there  is  incontinence  of  urine  a  permanent  urinal  may  be  used. 
When  redness  or  congestion  is  first  noticed,  the  skin  may  be  protected 
by  collodion,  soap  plaster,  or  a  thick  layer  of  some  bland  ointment. 
Irritants  of  all  sorts  should  be  avoided.  After  the  sore  has  formed 
it  should  be  cleansed  with  peroxid  of  hydrogen,  half  strength,  and 
bichlorid  of  mercury,  i  to  2000.'  Sloughs  should  be  removed  and 
.sinuses  opened.  In  very  large  bed  sores  the  patient  may  be  placed 
in  a  continuous  bath,  as  advised  for  burns.  Healing  may  be  stimu- 
lated as  already  indicated  in  the  section  on  ulcers. 

(c)  Corrosive  chemicals  directly  destroy  the  tissues.  Carbolic 
acid  gangrene  (Fig.  63)  requires  special  notice,  because  it  may  follow 
the  continuous  application  of  even  a  weak  solution  (1-20),  especially 
if  the  drug  is  confined  by  an  impervious  covering  under  a  tight  band- 
age. As  carbohc  acid  induces  anesthesia,  the  mischief  may  not  be 
suspected  if  the  dressing  remain  undisturbed.  The  condition  is 
most  frequently  seen  in  a  finger  or  toe,  and  is  of  the  dry  variety. 


134  MANUAL  OF  SURGERY 

If  an  entire  linger  or  toe  be  gangrenous,  wait  for  a  line  of  demarcation 
and  amputate.  If  the  superficial  parts  only  are  affected,  assist 
separation  of  the  slough  with  hot  fomentations  and  remove  it  with 
scissors. 

(d)  X-ray  gangrene  is  considered  in  chap,  i,  (e)  frost  bites  and 
(f)  burns  and  scalds  in  chap.  xi. 

(3)  MICROBIC  GANGRENE 

Infective  gangrene  occurs  in  various  parts  of  the  body,  and  may 
be  localized  or  diffuse.  The  localized  form  (e.g.,  carbuncle,  necrosis 
of  bone)  is  described  in  subsequent  chapters.  The  diffuse  form  has, 
according  to  the  character  of  the  infection  and  the  resistance  of  the 
tissues,  numerous  gradations  (see  "Cellulitis"),  but  only  three 
varieties  will  be  considered  at  this  time. 

Gas  gangrene  (emphysematous  gangrene,  malignant  edema)  is  due 
to  the  action  of  saprophytes  on  devitalized  tissue,  especially  muscle. 
The  infection  is  always  a  mixed  one,  the  suppuration  depending  upon 
the  ordinary  pyogenic  bacteria,  especially  the  streptococcus,  and  the 
emphysema  upon  the  saprophytes.  The  latter,  with  the  exception 
of  the  colon  group,  are  anaerobes  and  grow  symbiotically  with  the 
aerobes.  The  anaerobes  may  be  divided  into  two  classes,  (i)  the 
saccharolytic,  of  which  the  B.  aerogenes  capsulatus  is  the  most 
important  member,  and  (2)  the  proteolytic,  represented  by  the  B. 
sporogenes.  (i)  The  B.  aerogenes  capsulatus  of  Welch,  the  most 
important  cause  of  gas  gangrene,  is  identical  with  the  B.  phlegmonis 
emphysamatosse  of  Fraenkel  and  the  B.  perfringens  of  Veillon. 
The  glycogen  of  living  muscle  is  converted  after  death  into  dextrose 
and  a  small  fraction  of  isomaltose  (Henry),  which  are  fermented  by 
the  B.  aerogenes  capsulatus,  resulting  in  the  formation  of  acid 
(butyric,  acetic,  lactic,  proprionic)  and  gas.  The  bacillus  produces  an 
ectotoxin  (Bull  and  Prichett),  which,  by  necrosing  adjacent  tissue, 
provides  for  the  further  invasion  of  the  organism.  Necrosis  is 
favored  also  by  the  pressure  of  the  gas,  the  inflammatory  exudate, 
and  in  many  cases  by  the  damaged  blood  supply.  (2)  The  B. 
sporogenes  is  closely  related  to,  if  not  the  same  as,  the  bacillus  of 
mahgnant  edema,  the  vibrion  septique,  the  B.  putrificus,  the  B. 
cadaveris  sporogenes.  It  grows  symbiotically  with  the  B.  of  Welch, 
and  acts  on  proteins,  breaking  them  down  into  amido-acids,  from 
which  the  amin  group  is  separated,  yielding  ammonium  salts  of  the 
fatty  acids.  "It  is  probable  that  these  and  some  of  the  intermediate 
by-products  play  some  part  in  the  local  spread  of  the  infection,  and 


GANC.RKNE  I35 

also  assist  in  producing  general  toxic  symptoms"  (Petrie).  Of  the 
various  otlicr  saprophytes  that  have  been  found  in  cases  of  gas  gan- 
grene, most  are  noni)athogenic,  though  some  are  thought  to  aid  in 
the  growth  of  the'  forms  mentioned  al)ove.  Gas  gangrene  is  excep- 
tional in  civil  life,  but  proved  during  the  war  to  be  a  frequent  com- 
plication of  shell  wounds  involving  the  muscles.  The  infecting 
bacteria  are  of  fecal  origin,  hence  numerous  in  cultivated  soil,  and 
in  the  clothing  and  on  the  skin  of  soldiers  in  the  trenches.  A  shell 
fragment  often  lodges  and  carries  with  it  into  the  body  pieces  of 
contaminated  clothing  or  skin;  in  addition  a  shell  wound  of  muscle 
provides  all  the  conditions  needed  for  the  development  of  saprophytic 
anaerobes,  namely  (i)  dead  tissue,  which  is  (b)  rich  in  glycogen,  and 
(c)  shut  ofY  from  the  air  in  irregular  pockets.  Gas  gangrene  is  most 
frequent  in  the  lower  limb  and  about  the  buttocks,  and  very  rare  in 
the  head  and  neck.  It  may  spread  longitudinally  in  a  single  muscle 
without  affecting  neighboring  ones,  but  if  the  principal  artery  is 
occluded  all  of  the  muscles  which  it  supplies  are  involved  simultane- 
ously. When  a  large  hematoma  is  infected,  the  symptoms  may, 
owing  to  the  defensive  powers  of  fresh  serum,  be  delayed  for  several 
days.  At  autopsy  the  bacilli  and  the  gas  are  found  in  the  heart 
and  the  blood  vessels,  although  during  life  blood  cultures  are  often 
sterile. 

The  symptoms  are  those  of  moist  gangrene  with  emphysema. 
The  period  of  incubation,  and  in  fatal  cases  the  duration  of  the  dis- 
ease, vary  from  a  few  hours  to  several  days.  The  wound  is  covered 
with  sloughs,  emits  a  sweetish  foul  odor,  and  discharges  a  thin  brown 
serum.  The  surrounding  parts  are  swollen  and  painful.  In  the 
beginning  the  skin  becomes  tense  from  pressure,  consequently  pale, 
the  pallor  being  succeeded  by  a  dirty  cream  tint.  Then  appear  areas 
of  purple,  which  enlarge,  coalesce,  and  develop  blebs  containing  a 
blood-stained  fluid.  In  the  final  stage  the  color  of  the  skin  is  a  dark 
yellow-green  or  black.  Bronzing  is  less  frequent  on  the  limbs  than 
on  the  body.  The  muscles  change  from  the  normal  red-purple  color 
to  brick  red  (red  death),  then  to  yellow-green,  and  finally  to  greenish 
black  (black  death) ;  in  the  stage  of  red  death  they  are  noncon- 
tractile,  friable,  crepitant;  in  the  final  stage  ghstening,  soft,  putty- 
like (Wallace).  The  gas  makes  itself  known  by  fetor,  by  crepitation 
on  pressure,  by  tyftipany  on  precussion,  by  bubbling  through  the 
wound  or  through  an  incision,  and  by  the  light  areas  which  it  casts 
on  X-ray  examination.  The  general  symptoms  are  those  of  septi- 
cemia. The  mortality  varies  from  lo  to  50  per  cent,  or  more, 
depending  upon  the  extent  of  the  gangrene  and  the  time  of  the 


136  MANUAL  OF  SURGERY 

treatment.  The  most  frequent  complication  is  tetanus,  which  ac- 
cording to  Weinberg  and  Sequin,  occurs  in  13  per  cent,  of  the  cases. 

Prophylaxis,  after  the  wound  has  been  received,  includes  measures 
to  relieve  or  prevent  embarrassment  of  the  circulation,  e.g.,  the 
reduction  and  immobilization  of  fractures,  and,  if  possible,  avoidance 
of  the  tourniquet;  and  the  early  removal  of  foreign  bodies,  with  the 
excision  of  destroyed  tissue,  and  relief  of  the  tension  within  the 
muscle  sheaths  hy  generous  incisions  that  liberate  the  gas  and 
extrava sated  fluids. 

The  treatment  is  immediate  operation  under  nitrous  oxid  anesthe- 
sia. If  the  process  is  localized  to  a  single  muscle  or  a  small  group  of 
muscles,  the  diseased  tissue  may  be  excised,  the  resection  being  ex- 
tended until  the  color,  contractihty,  and  bleeding  of  the  muscular 
tissue  are  normal.  Amputation  is  indicated  if  the  gangrene  is  so 
extensive  that  resection  would  result  in  a  useless  hmb,  if  the  principal 
blood  vesels  have  been  destroyed,  if  the  patient  is  in  bad  condition, 
and  in  many  cases  in  which  the  bone  is  fractured.  Amputation  may 
be  performed  by  the  guillotine  method  (see  "Amputations"),  or 
with  short  flaps.  After  any  of  these  procedures  no  sutures  are 
inserted,  and  the  wound  is  treated  by  the  Carrel-Dakin  method  or 
one  of  its  substitutes.  The  general  treatment  is  that  of  sepsis. 
Several  antitoxins  have  been  tried,  but  sufhcient  data  are  lacking 
to  make  a  positive  statement  as  to  their  value. 

(c)  Noma  is  a  gangrenous  process  occurring  most  often  between 
the  second  and  twelfth  years.  Cancrum  oris  {gangrenous  stomatitis) 
is  noma  of  the  mouth  (Fig.  64) ;  noma  pudendi  is  the  same  process  in 
the  genitals;  the  condition  occasionally  occurs  in  other  parts.  About 
half  of  the  cases  follow  measles,  but  it  may  be  seen  after  other  in- 
fectious diseases,  and  occasionally  in  diabetes  and  nephritis.  A 
specific  organism  has  not  been  isolated.  The  sloughing  is  probably 
due  to  the  ordinary  pyogenic  bacteria  acting  on  tissues  whose  defen- 
sive powers  have  been  reduced  by  the  preceding  disease. 

The  symptoms  are  inaugurated  by  an  abrasion  of  the  mucous 
membrane,  which  becomes  inflamed  and  finally  sloughs.  The  part 
swells  and  becomes  extremely  fetid,  but  pain  is  not  a  prominent 
feature.  The  gangrene  rapidly  makes  its  way  through  the  whole 
cheek,  and  may  involve  even  the  adjacent  bone.  The  general 
symptoms  are  those  of  sepsis  (^q.v.) ;  occasionally  pyemia  arises  from 
involvement  of  the  facial  vein.  Inhalation  penumonia  is  very  apt 
to  develop.  Often  the  temperature  falls  to  normal  or  subnormal 
before  death,  which  occurs  in  from  70  to  90  per  cent,  of  the  cases. 

The  treatment  is  removal  of  the  slough  with  scissors,  and  cauteri- 


GANGRENE 


137 


zation  with  the  actual  cautery,  or,  after  protecting  the  throat  with 
gauze,  with  nitric  acid  or  carboHc  acid,  neutralizing  the  excess  of 
the  former  with  sodium  bicarbonate,  of  the  latter  with  alcohol.  A 
general  anesthetic  should  be  used  for  this  purpose,  remembering  that 
chloroform,  and  not  ether,  must  be  given  if  the  actual  cautery  is  to  be 
employed.     The  mouth  is  frequently  washed  with  boric  acid  solu- 


FiG.   64. — Noma  follu\vinj<  measles. 

tion  or  liquor  antisepticus.  Hot  antiseptic  fomentations  of  boric 
acid  are  applied  to  the  exterior,  and  the  patient  is  given  nourishing 
liquid  food,  w^ith  alcohol,  iron,  and  strychnin.  If  recovery  ensues, 
the  loss  of  tissue  may  be  supplied  by  a  plastic  operation.  In  noma 
pudendi,  in  addition  to  the  measures  already  mentioned,  the  patient 
may  be  placed  in  an  antiseptic  bath. 


CHAPTER  X 
CONTUSIONS  AND  WOUNDS 

Mechanical  injuries  of  the  tissues  are  of  two  kinds,  contusions  and 
wounds. 

A  contusion  is  an  injury,  generally  the  result  of  blunt  violence, 
in  which  some  of  the  tissues  of  a  part  are  irregularly  torn  or  ruptured, 
but  the  part  as  a  whole  remains  intact  and  its  surface  continuity 
unbroken.  It  may  occur  in  any  region,  but  here  we  refer  only  to 
contusions  of  the  skin  and  subjacent  cellular  tissue.  Contusions  of 
special  structures  are  discussed  on  subsequent  pages. 

The  symptoms  are  pain,  tenderness,  swelling,  discoloration, 
impaired  function,  and  in  severe  forms  shock.  In  some  instances 
there  is  pronounced  numbness,  which  may  last  for  a  number  of  hours. 
The  swelhng  is  due  partly  to  exudation,  but  principally  to  subcu- 
taneous bleeding  {extravasation) ,  the  blood  either  infiltrating  the 
tissues  (ecchymosis,  or  sugillation)  or  accumulating  as  a  localized 
fluctuating  swelling  (hematoma).  An  ecchymosis  when  minute  is 
called  a  petechia,  when  very  large  a  suffusion..  The  amount  of  blood 
extravasated  varies  with  the  size  of  the  vessels  injured  and  the  con- 
struction of  the  part,  thus  in  lax  tissues,  e.g.,  the  scrotum  and  eyelids, 
it  is  generally  extensive,  in  the  scalp  slight.  It  is  apt  to  be  excessive 
in  the  delicate,  in  females,  in  hemophilia  and  allied  conditions,  and  tri- 
fling in  the  robust.  The  blood  in  an  ecchymosis  soon  coagulates  and 
is  disintegrated  and  absorbed;  the  red  corpuscles  liberate  pigment, 
which,  as  seen  through  the  skin,  is  at  first  black,  then  blue,  changing, 
as  absorption  progresses,  to  brown,  green,  yellow,  and  finally  disap- 
pearing. A  hematoma  is  surrounded  by  a  deposit  of  fibrin,  so  that 
the  edges  feel  hard  and  the  center  soft;  it  may  be  absorbed,  converted 
into  a  fibroid  mass,  become  inspissated  and  calcified,  result  in  a  cyst, 
or  suppurate.  A  hematoma  differs  from  an  abscess  in  that  it  appears 
immediately  after  an  injury  without  signs  of  inflammation,  and  is  at 
first  soft  and  later  hard,  while  an  abscess  is  first  hard  and  later  soft. 
A  contusion  may  terminate  in  resolution,  inflammation,  suppuration, 
sloughing,  fibroid  thickening,  or  tumor  formation,  particularly 
sarcoma,  and  it  sometimes,  by  establishing  a  point  of  lessened  re- 
sistance, determines  the  site  of  chronic  infective  lesions,  notably 
tuberculosis.     The  possibility  of  a  comphcating  injury  to  important 

138 


CONTUSIONS    AND    WOl^NDS  I39 

vessels  or  nerves,  to  muscles,  tendons,  bones,  joints,  and  viscera 
should  al\va)'s  he  ke|)t  in  mind. 

The  treatment  of  contusions  is  first  to  combat  shock,  if  it  be 
present,  and  locally,  to  check  bleeding  and  limit  swelling,  by  means 
of  ice,  evaporating  lotions,  compression,  elevation,  and  rest.  In  the 
asthenic,  and  in  severe  contusions  in  which  there  is  danger  of  slough- 
ing, heat  with  very  moderate  compression,  should  be  employed.  In 
the  presence  of  an  abrasion  hot  or  cold  antiseptic  dressings  should  be 
applied.  During  the  subsiding  stage  ichthyol,  compression,  and 
massage  will  hasten  absorption.  Incision  is  not  indicated  unless  a 
large  vessel  has  been  injured,  or  unless  the  tension  is  so  great  as  to 
threaten  sloughing.  If  a  hematoma  persists,  it  may  be  aspirated 
and  firm  compression  applied.  The  slight  fever  which  results  from 
the  absorption  of  the  fibrin  ferment  of  the  extravasated  blood  needs 
no  special  treatment. 

A  wound  is  a  mechanical  injury  with  a  breach  in  the  surface 
continuity.  Wounds  may  be  incised,  contused,  or  lacerated; 
punctured;  gunshot;  aseptic,  contaminated  (see  "Infection,"  chap, 
iii),  or  septic  (infected);  poisoned;  complicated  or  uncomplicated; 
penetrating  (which  enter  but  do  not  go  through  a  part)  or  perforating 
(which  go  entirely  through  a  part) ;  open  or  closed  (subcutaneous  or 
submucous).  Closed  wounds  include  ruptures  of  muscles,  viscera, 
etc.,  and  fractures  of  bones.  An  abrasion ,  or  excoriatioft,  is  a  rub- 
bing off  of  the  epidermis  without  breaking  of  the  corium,  a  brush 
burn  a  superficial  contused,  lacerated,  burned  wound  caused  by  fric- 
tion and  the  resulting  heat,  as  when  an  individual  rapidly  slides 
down  a  steep  incline. 

The  symptoms  of  uncomplicated  wounds  are  pain,  hemorrhage, 
•gaping  of  the  edges,  loss  of  function,  and  in  severe  wounds  shock. 

The  steps  in  the  treatment  that  may  be  needed  should  proceed 
in  the  following  order:  (i)  temporary  hemostasis,  (2)  attention  to 
the  shock,  (3)  disinfection  (mechanical  and  chemical)  and  permanent 
hemostasis,  (4)  suture,  (5)  drainage,  (6)  dressing,  (7)  rest. 

1.  Temporary  hemostasis  is  affected  usually  by  direct  pressure 
or  the  application  of  a  tourniquet  (see  "Hemorrhage,"  chap.  xv). 

2.  Shock  is  treated  as  outlined  in  chap.  xii.  Its  presence  forbids, 
as  a  rule,  anything  more  than  provisional  control  of  the  bleeding 
and  the  application  of  a  temporary  dressing. 

3.  Disinfection  in  many  cases  can  be  accomplished  only  after 
the  administration  of  an  anesthetic.  The  skin  and  the  wound  are 
often  painted  with  iodin  (chap.  iv).  Mechanical  disinfection,  i.e., 
removal  of  foreign  bodies  and  devitalized  tissue,  or  excision  of  the 


140 


MANUAL  OF  SURGERY 


whole  wound,  may  be  needed.  Chemical  disinfection  ma}-  be  em- 
ployed, as  indicated  later.  Permanent  hemostasis,  generally  by 
ligation,  must  be  assured  (chap.  xv). 

4.  The  margins  of  the  wounds  may  be  coaptated  by  bandaging,  by 
sterilized  adhesive  plaster,  by  gauze  plastered  down  with  collodion, 
or  by  small  metal  clips  with  serrated  edges  {Michel  clamps)  which  are 
apphed  and  removed  with  special  forceps,  but  these  measures  are 
not  nearly  so  satisfactory  as  sutures.  Deep  parts  should  be  approxi- 
mated with  buried  sutures  of  catgut,  \\hen  the  edges  tend  strongly 
to  retract,  or  when  a  wound  is  deep,  two  varieties  of  sutures  will  be 
required,  viz.,  deep  sutures  {retention  sutures,  or  sutures  of  relaxation) 
and  superficial  sutures,  or  sutures  of  coaptation  (Fig.  65).  Retention 
sutures  are  usually  of  silkworm  gut,  but  may  be  of  silk  or  silver  wire; 
they  are  inserted  an  inch  or  more  from  the  margins  of  the  wound, 


Fig.  65. — On»  the  left   a  continuous  Glover's  suture.     In  the  middle  one  deep  and 
two  superficial  interrupted  sutures.     On  the  right  continuous  button  hole  suture. 

traverse  the  entire  thickness  of  the  divided  parts,  and  are  then  tied. 
The  button  suture,  the  quill  suture,  and  the  twisted  suture  (Fig. 
66)  are  varieties  of  the  retention  suture.  Superficial  sutures  are 
inserted  near  the  margins  of  the  wound  for  coaptation  only;  they 
should  not  be  tight  enough  to  produce  wrinkling  or  to  invert  the 
edges  of  the  skin.  In  the  former  instance  stitch  abscess  is  fostered, 
in  the  latter  healing  is  prevented.  We  frequently  employ  a  combined 
retention  and  coaptation  suture  as  shown  in  Fig.  67.  The  interrupted 
suture  consists  of  separate  stitches,  tied  so  that  the  knot  rests  over 
one  of  the  suture  holes,  and  not  on  the  wound.  The  continuous  or 
Glover's  stitch  (Fig.  65)  traverses  the  entire  length  of  the  wound 
without  interruption.  The  button-hole  stitch  (Fig.  65)  makes  tension 
at  right  angles  to  the  wound.  "When  desirable  a  continuous  suture 
may  be  tied  after  each  insertion  (Fig.  68) .  The  Halsted  subcuticular 
suture  (Fig.  69)  is  a  continuous  suture  inserted  into  the  deeper  layers 


CONTUSIONS    AND    WOITNDS 


141 


of  the  skin,  but  not  penctniting  the  epidermis.  Catgut  is  the  best 
material  for  this  suture,  although  silkworm  gut  or  silver  wire  is  often 
used,  the  ends  being  left  long  and  protruding  from  each  angle  of  the 


,-.@ 

fl 


y 


Fig.  66.  Fig.  67. 

Fig.  66. — A,  Upper  button  suture,  B,  Middle  Quill  suture,  C,  Lower  twisted  suture- 
Fig.  67. — Combined  retention  and  coaptation  .suture.  The  needle  is  inserted  at  i' 
brought  out  at  2,  reinserted  at  3,  and  emerges  at  4,  passing  through  the  loop  at  5. 
When  drawn  tight  it  holds  the  wound  edges  firmly  together  and  prevents  inversion  of 
the  skin,  as  shown  in  the  lower  part  of  the  illustration. 

wound,  so  that  it  may  be  removed  when  healing  is  complete.  The 
suture  gives  a  fine  cicatrix  without  the  presence  of  suture  scars. 
Theoretically  the  staphylococcus  epidermidis  albus  lies  undisturbed 


Fig.  68. — Ford's  suture:  showing  two  square 
knots,  a  single  knot,  and  the  method  of  com- 
pleting a  square  knot.      (DaCosta.) 


Fig.   69. — Halsted's  sub- 
cuticular suture. 


in  the  superficial  layers  of  the  skin  and  does  not  cause  stitch  abscesses. 
Care  should  be  taken  to  approximate  the  deeper  structures  with  cat- 
gut or  to  apply  firm  pressure,  so  that  the  dead  space  beneath  will  be 
obhterated  and  the  formation  of  a  hematoma  prevented.     Other 


142 


MANUAL  OF  SURGERY 


varieties  of  sutures  are  described  in  connection  with  the  operations 
for  which  they  are  used.  Sutures  should  be  tied,  not  in  a  granny 
knot  (Fig.  70),  but  in  a  reef  knot  (Fig.  71),  or,  if  there  is  much  tension, 
in  a  surgeon's  knot  (Fig.  72).  Sutures  are  removed  in  from  seven 
to  ten  days,  or  at  any  time  if  they  cut  or  the  wound  becomes  infected. 
In  removing  a  suture  the  exposed  portion  should  not  be  dragged 
through  the  tissues,  because  of  the  possibihty  of  infection  (Fig.  73). 
5.  Drainage  is  discussed  in  the  chapter  on  "  Technic." 


Fig.    70. — Granny  knot. 


Fig.    71. — Reef  knot.  Pig.   72. — Surgeon's  knot. 


6.  The  dressing,  if  the  wound  is  closed,  is  dry  sterile  gauze,  re- 
tained in  place  by  a  bandage  or  binder.  In  infected  wounds  a  dress- 
ing wet  with  bichlorid  of  mercury,  1—5000,  or  other  antiseptics,  may 
be  employed. 

7.  Rest  is  secured  by  confining  the  patient  to  bed,  in  serious  cases, 
or  by  splints,  slings,  sedatives,  etc.  Reference  has  already  been  made 
to  some  of  the  comphcations  of  wounds,  viz.,  inflammation,  suppura- 
tion, and  gangerene,  others  are  dis- 
cussed in  Chap.  xii. 

Incised  wounds  are  those  in 
which  the  edges  are  cleanly  cut 
and  sharply  defined;  they  are 
usually  produced  by  keen  instru- 
ments, but  occasionally  by  blunt 
force,  e.g.,  the  clean-cut  wound  of 
the  scalp  which  may  result  from 
the  blow  of  a  club.  Pain  is  severe 
at  the  time  of  injury,  but  usually 
subsides  quickly;  bleeding  is  pro- 
fuse because  the  vessel  walls  have  not  been  squeezed  together  but 
cleanly  severed.  The  gaping  depends  upon  the  length  and  situation 
of  the  wound,  being  wide  when  the  wound  crosses  and  slight  when 
it  parallels  muscle  fibres  or  a  line  of  "cleaveage"  in  the  skin,  which 
line  is  often  marked  by  a  wrinkle.  The  amount  of  bruising  pres- 
ent is  only  miscroscopic,  so  that  with  reasonable  precautions  an  in- 
cised wound  heals  by  first  intention. 

Treatment. — ^Bleeding  ceases  spontaneously  if  no  large  vessel 
has  been   injured.     If  a  large  vessel  has  been  injured,  it  may  be 


Fig.  73. — One  side  of  the  suture  is 
drawn  out  of  the  tissues  a  short  distance 
and  cut  close  to  the  skin.  Steady  trac- 
tion perpendicular  to  the  skin,  in  the 
direction  of  the  arrow,  is  then  made  on 
the  other  side,  holding  back  the  skin,  if 
need  be,  with  the  separated  blades  of  the 
scissors. 


CONTUSIONS    AND    WOUNDS  1 43 

caught  at  once  with  hemostatic  forceps,  compressed  with  a  sterile 
sponge,  or  controlled  by  a  tourniquet  above  the  wound.  In  the 
meantime  measures  sliould  be  taked  to  combat  shock  if  it  be  j)resent. 
After  careful  disinfection  a  thorough  examination  is  made  to  deter- 
mine the  amount  of  injury  done.  Divided  nerves,  tendons,  or 
muscles  may  be  seen  in  the  wound,  sensation  and  motion  may  be  in- 
vestigated in  the  parts  beyond  the  wound.  If  any  of  these  structures 
have  been  severed,  they  are  to  be  sutured  with  chromicized catgut. 
Drainage  is  seldom  necessary. 

A  contused  wound  is  one  whose  edges  are  bruised  as  the  result 
of  a  crushing  or  tearing  force.  A  lacerated  wound  is  one  whose  edges 
are  irregular  or  torn,  and  is  produced  in  the  same  way  as  a  contused 
wound.  Since  contusion  and  laceration  are  commonly  associated, 
these  wounds  will  be  discussed  together.  The  bleeding  is  often 
trivial,  owing  to  the  fact  that  the  vessels  are  torn;  the  inner  and 
middle  coats  give  way  first,  curl  up,  and  plug  the  vessel.  In  other 
cases  the  vessels  are  crushed,  and  the  walls  adhere  to  each  other 
with  (Sufficient  firmness  to  stop  hemorrhage.  The  edges  separate 
less  widely  than  in  an  incised  wound  of  the  same  size,  but  the  amount 
of  devitalized  tissue  is  much  greater,  and  before  repair  occurs  this 
must  be  removed  by  the  surgeon  or  by  nature.  As  nature's  method 
is  usually  suppuration,  wounds  of  this  character  are  very  apt  to 
heal  by  second  intention.  Wound  complications  and  shock  are 
much  more  frequent  than  in  incised  wounds.  Among  contused 
and  lacerated  wounds  are  some  of  the  most  dreadful  which  a  surgeon 
is  called  upon  to  treat,  such  as  those  resulting  from  the  tearing  oft" 
of  a  scalp  or  the  avulsion  of  a  limb. 

The  treatment  in  a  severe  contused-lacerated  wound,  in  the 
absence  of  urgent  hemorrhage,  is  first  directed  to  the  shock.  After 
this  has  subsided,  the  patient  should  be  anesthetized  in  order  to  thor- 
oughly disinfect  the  wound.  Tissue  whose  vitality  is  questioned 
should  be  removed  if  it  is  unimportant,  in  other  cases  it  should  be 
retained  unless  known  to  be  badly  infected.  All  visible  wounded 
vessels,  whether  bleeding  or  not,  are  ligated.  After  mechanical  dis- 
infection germicides  may  be  omitted,  or  the  wound  may  be  treated 
with  dichloramin — T  or  other  antiseptic.  If  the  operation  is  done 
during  the  stage  of  contamination,  i.e.,  within  12  or  rarely  24  hours 
of  the  injury,  if  all  potentially  infected  tissue  is  excised,  and  if  the 
bleeding  is  controlled  completely,  the  wound  may  be  closed  without 
drainage.  Under  other  circumstances  the  wound,  if  bacterial  smears 
do  not  show  the  presence  of  streptococci,  may  be  treated  by  the 
Carrel-Dakin  method  and  closed  at  a  later  period,  as  described  in 


144  MANUAL    OF    SURGERY 

the  section  on  "Mechanical  Disinfection " under  "Gunshot  Wounds." 
If  the  wound  is  closed  and  sepsis  manifests  itself  it  must  be  opened, 
disinfected,  and  drained.  The  treatment  of  sloughing  will  be  found 
in  the  chapter  on  "Ulceration;"  of  secondary  hemorrhage,  in  the 
chapter  on  "Hemorrhage;"  and  the  indications  for  amputation,  in 
the  chapter  on  "Amputations." 

Punctured  wounds  and  stabs  are  deep,  narrow  wounds  caused 
by  any  long,  narrow  instrument,  from  a  needle  to  a  sword.  The 
outer  opening  is  trivial  in  size,  the  danger  depending  upon  the  injury 
to  the  deeper  structures  and  the  nature  of  the  infection  which  may 
have  occurred.  These  wounds  are  especially  favorable  for  the 
development  of  anaerobic  organisms,  the  most  important  of  which 
is  the  tetanus  bacillus. 

The  treatment  depends  upon  the  character  of  the  vulnerating 
instrument  and  the  damage  which  has  been  inflicted.  If  possible, 
the  instrument  should  be  inspected  to  ascertain  if  any  portion  of 
it  has  been  broken  off  and  left  in  the  tissues.  The  X-ray  also  may 
be  used  for  this  purpose.  Practically  all  punctured  wounds,  espe- 
cially those  known  to  be  contaminated,  such  as  those  produced  by 
dirty  nails  or  the  teeth  of  animals,  should  be  excised,  or,  if  this  is 
injudicious,  incised,  disinfected,  and  drained,  any  foreign  body 
which  may  be  present  being  removed  at  the  same  time.  Instruments 
like  fish-hooks,  and  needles  with  barbed  ends,  which  become  entan- 
gled in  the  tissues,  require  incision  for  their  extraction,  or  removal 
of  the  barb  after  it  has  been  pushed  through  adjacent  skin.  After 
all  punctured  wounds  a  prophylactic  injection  of  tetanus  antitoxin 
should  be  given.  Punctured  wounds  or  stabs  may  injure  large 
vessels,  nerves,  tendons,  or  any  of  the  viscera.  Injuries  of  these 
structures  are  dealt  with  in  later  chapters. 

Gunshot  wounds  are  a  special,  variety  of  contused -lacerated 
wounds,  produced  by  missiles  thrown  by  explosives. 

In  civil  life  gunshot  wounds  are  usually  produced  by  small  shot. 
revolver  and  hunting  rifle  bullets,  and  blank  cartridges.  The 
bullet  of  civil  life  is  made  of  lead,  moves  at  a  low  velocity  (700  ft. 
per  second),  is  readily  deformed,  frequently  lodges  in  the  tissues, 
often  carries  with  it  particles  of  clothing  and  skin,  and  always  causes 
a  potentially  infected  wound.  The  entrance  wound  is  slightly 
smaller  than  the  bullet,  and  may  be  punched  out,  ragged,  or  inverted. 
The  tract  of  the  bullet  is  surrounded  by  contused  and  devitalized 
tissue.  The  wound  of  exit  is  larger  than  the  bullet,  everted,  and 
more  ragged  than  the  wound  of  entrance.  The  bullet  is  apt  to  be 
deflected  by  bone  or  dense  fascia,  and  often  pushes  nerves,  tendons, 


CONTUSIONS    AND    WOUNDS  1 45 

and  blood  vessels  out  of  the  way  instead  of  cuttinf]j  them,  so  that 
serious  primary  hemorrhage  is  usually  absent,  although  secondary 
hemorrhage  from  sloughing  of  contused  vessels  may  occur.  Injured 
bones  are  generally  spHntered  or  comminuted.  Small  sJiol,  if  at 
close  range,  produces  extensive  laceration  and  burning  of  the  tissues, 
into  which  are  driven  the  shot,  powder-grains,  and  portions  of  the 
clothing.  At  a  longer  range  the  shot  may  simply  contuse  the  tissues 
without  entering,  or  may  enter  and  be  scattered  in  the  soft  parts, 
usually  producing  little  damage  unless  a  delicate  structure  Uke 
the  eye  has  been  struck.  Wounds  by  blank  cartridges  are  con- 
tused, lacerated,  burned  wounds,  in  the  depths  of  which  a  wad  is 
lodged,  and  are  especially  dangerous  because  of  the  frequency  with 
which  tetanus  follows. 

The  treatment  of  wounds  due  to  the  leaden  bullet  is,  first,  if 
necessary,  temparary  hemostasis  and  attention  to  the  shock.  The 
skin  is  painted  with  iodin,  a  sterile  dressing  applied,  and  the  position 
of  the  bullet,  if  lodged,  determined  with  the  X-ray.  In  addition, 
one  should  ascertain  the  direction  from  which  the  bullet  was  fired 
and  the  position  of  the  body  at  the  time,  examine  the  clothing  for 
the  position  of  perforations  in  relation  to  the  skin  woiind  as  well 
as  to  determine  whether  portions  are  absent,  and  see  whether  or 
not  there  is  a  wound  exit.  Probing  is  contraindicated.  In  the 
first  12  or  24  hours  the  best  treatment,  when  the  bullet  is  easily 
accessible,  is  excision  of  the  wound,  with  removal  of  the  bullet  and 
any  other  foreign  bodies  that  may  have  been  carried  in  with  it.  If 
the  bullet  must  be  sought,  the  best  instrument  is  the  finger,  which 
detects  not  only  metalhc  substances,  but  also  pieces  of  clothing  and 
other  foreign  bodies  not  demonstrable  by  the  X-ray  or  probes. 
Electrical  devices  and  similar  forms  of  apparatus  are  useless  when 
digital  exploration  fails,  superfluous  when  it  does  not  fail. 
After  removing  a  bullet  the  wound  may  be  treated  as  advised  in 
the  section  on  "  Contused-lacerated  Wounds. "  If  the  patient  comes 
under  observation  after  the  first  day,  if  a  large  number  of  shot  are 
scattered  in  the  tissues,  or  if  a  formidable  operation  would  be 
necessary  to  reach  the  bullet,  less  risk  will  often  be  taken  by  leaving, 
than  by  removing,  the  foreign  body  or  bodies,  unless  serious 
comphcations  are  present.  In  all  cases  a  prophylactic  injection  of 
tetanus  antitoxin  should  be  given.  The  treatment  of  bullet  wounds 
of  the  head,  chest,  abdomen  and  of  special  structures  is  considered 
in  the  sections  on  regional  surgery. 

Blank  cartridge  wounds  should  invariably  be  treated  by  anesthe- 
tizing the  patient,  removing  the  wad  and  devitalized  tissues,  care- 
10 


146  MANUAL    OF    SURGERY 

fully  disinfecting  the  wound,  and  draining  it  with  gauze.-  The 
administration  of  a  prophylactic  dose  of  antitetanic  serum  also 
is  strongly  recommended  (see  "Tetanus"). 

Gunpowder  stains  are  best  removed  by  picking  out  each  grain 
with  a  sharp  pointed  tenotome.  Irritating  ointments  followed  by 
poulticing  may  be  used  with  the  hope  that  the  grains  will  be  discharged 
by  suppuration.  The  application  of  equal  parts  of  ammonium  iodid 
and  distilled  water  has  been  recommended;  the  spots  gradually 
turn  red,  and  the  red  marks  are  faded  by  the  apphcation  of  dilute 
hydrochloric  acid.  Electrolysis  and  caustics  cause  permanent 
scarring.  When  the  stains  are  quite  superficial,  the  upper  layer 
of  the  skin  may  be  shaved  off,  and  the  raw  surface  covered  with  a 
Thiersch  graft. 

In  military  surgery  gunshot  wounds  differ  from  those  in  civil 
life,  not  only  in  character,  but  also  because  serious  infection  is  much 
more  frequent,  notably  with  anaerobes  (of  ''Gas  Gangrene''  and 
''Tetanus").  The  modern  rifle  bullet,  with  the  exception  of  the 
solid  bronze  bullet  used  by  the  French,  consists  of  a  lead  core, 
enclosed  in  a  dense  jacket,  usually  of  cupronickel  or  ferronickel. 
It  is  long,  conical,  and  of  reduced  calibre,  generally  between  6.5  and 
8  mm.  The  muzzle  velocity  is  very  great,  650  meters  and  upward 
per  second,  the  bullet  revolving  on  its  own  axis  as  the  result  of  the 
rifling  some  2000  times  or  more  the  first  second;  it  is  capable  of 
producing  a  mortal  wound  at  4000  meters  distance.  The  trajectory 
is  comparatively  flat,  hence  the  accuracy  of  aim.  Owing  to  its 
high  speed,  small  cahbre,  and  dense  jacket  the  bullet  rarely 
(10  per  cent.)  lodges  in  the  body  or  carries  particles  of  skin  or 
clothing  with  it,  and  it  is  seldom  deflected  or  deformed  by  the 
dense  tissues,  unless,  as  the  result  of  great  range  (over  1200  meters) 
or  ricochet,  the  velocity  is  diminished,  when  the  modern  bullet  may 
behave  much  like  the  leaden  one.  A  hard-jacketed  bullet  moving 
at  the  rate  of  2000  ft.  per  second  perforates  any  portion  of  the  body 
and  still  maintains  its  form,  "but  as  the  velocity  drops  there  comes 
a  point  when  the  resistance  is  too  great  for  the  momentum  of  the 
bullet  to  overcome  quickly,  and  then  the  bullet  piles  up  on  itself, 
just  as  it  does  when  it  strikes  a  very  hard  object,  and  the  lead  crowds 
to  the  front  of  the  bullet  till  the  nose  of  the  jacket  bursts"  (Wads- 
worth).  Ricochet  not  only  slows  but  may  deform  the  bullet,  and 
is  more  frequent  than  with  the  leaden  projectile,  which,  instead 
of  skipping  when  it  strikes  an  object,  is  apt  to  flatten  and  stop. 
The  character  of  the  wound  varies  according  to  the  tissue  injured, 
the  range  or  velocity  of  the  bullet,  which  determines  the  position  of 


CONTUSIONS    AND    WOUNDS  I47 

the  bulkt  when  it  enters,  by  the  })oint,  base  or  side  on,  and  accord- 
ing to  whether  or  not  it  is  deformed.  In  the  soft  parts  (muscle,  fascia, 
skin,  vessels,  nerves,  tendon)  direct  shots,  up  to  about  2000  meters, 
produce  a  clean  perforation.  The  wound  of  entrance  is  slightly 
smaller  than  the  bullet,  with  cleanly  cut  depressed  margins;  the 
wound  of  exit  is  slightly  larger  than  the  bullet  and  often  stellate 
or  slit-like.  A  large,  lacerated  wound  of  exit  may  be  produced  by 
a  fracture  of  bone,  the  splinters  being  driven  onward  by  the  bullet. 
The  walls  of  the  tract  are  apt  to  be  smooth,  with  very  little  tearing  or 
laceration.  The  bullet  is  not  deflected  by  bone  or  fascia,  and  it 
severs  instead  of  pushing  aside  nerves,  tendons,  and  blood  vessels, 
thus  increasing  the  frequency  of  violent  primary  hemorrhage.  Violent 
bleeding,  however,  is  rarely  seen  by  the  surgeon,  because  the  patient 
dies  quickly,  or  as  the  result  of  the  small  size  of  the  wound  of  entrance 
and  exit  and  a  small  opening  in  the  vessel,  an  aneurysm  forms; 
in  recent  wars  in  which  this  bullet  has  been  used,  arteriovenous 
aneurysm  has  been  comparatively  frequent.  These  wounds  are 
often  sterile,  and,  if  subsequent  infection  is  prevented,  may  heal 
by  primar}'  union.  The  percentage  of  infections  in  those  reaching 
the  hospital  has  varied  from  15  (Balkan  wars)  to  50  (Manchurian 
campaign).  Great  destruction  of  tissue  occurs  under  certain 
conditions.  At  close  range  (under  500  meters)  there  is  an  explosive 
effect,  due  to  waves  of  force  transmitted  from  the  bullet  to  the 
surrounding  parts.  This  effect  is  still  seen  in  the  brain,  parenchy- 
matous organs,  hollow  viscera  containing  fluid,  and  in  the  diaphyses 
of  long  bones  up  to  1000  meters,  ' 'while  clean  perforations  in  the 
liver,  spleen,  and  kidneys  can  hardly  be  said  to  occur  at  any  range." 
Lacerated  wounds  are  produced  also  by  deformed  bullets,  by  bullets 
which,  owing  to  lateral  deviation,  enter  side  on,  and  by  spKnters 
of  shattered  bone.  Pain  is  usually  sHght  at  the  time  of  injury, 
but  later  may  become  very  severe.  In  cancellous  bone  a  clean 
perforation  is  produced,  but  in  hard  bone  there  is  comminution, 
gradually  diminishing  with  increased  range;  "typical  perforations 
in  the  diaphyses  are  not  to  be  expected  at  any  range."  At  close 
range  soft  bone  may  be  splintered.  At  short  range  wounds  of  the 
head  are  extensive  and  practically  always  fatal;  over  1600  meters, 
clean  perforations  may  occur;  and  beyond  2000  meters  the  bullet 
may  lodge,  comparatively  little  harm  being  done  unless  an  active 
portion  of  the  brain  is  injured.  Abdominal  wounds  are  less  serious 
than  with  the  old  bullet,  but  still  give  a  very  large  mortahty.  Chest 
wounds  are  decidedly  less  dangerous  than  formerly,  excepting  those 


148  MAXUAL    OF    SURGERY 

cases  which  die  at  once  from  hemorrhage.  Of  those  wounded  by 
the  "humane"  bullet  about  10  per  cent,  die  on  the  field  or  in  the 
ambulance,  thus  the  immediate  mortahty  is  greater  than  with  the 
leaden  projectile,  but  in  virtue  of  the  morphologic  and  balhstic 
properties  of  the  modern  bullet,  and  of  the  antiseptic  and  con- 
servative treatment  of  the  modern  surgeon,  the  ultimate  mortality 
of  those  who  do  not  succumb  on  the  battle  field  is  comparatively 
small. 

Shell  and  shrapneU  wounds  produce  contused-lacerated,  poten- 
tially infected  wounds,  containing  fragments  of  the  projectile  and 
often  particles  of  clothing. 

The  treatment  of  gunshot  wounds  on  the  battle-field  is  Hmited 
to  the  arrest  of  bleeding  by  tourniquet  or  other  form  of  compression, 
the  temporary  splinting  of  fractured  limbs,  and  the  protection  of 
wounds  from  infection  by  the  application  of  an  antiseptic  dressing, 
a  small  package  of  which  is  carried  by  each  soldier.  At  the  first 
aid  post  or  one  of  the  dressing  stations  farther  back  from  the  front 
the  wounds  are  reviewed,  perhaps  disinfected  with  iodin,  bleeding 
points  hgated,  and  antitetanic  serum  and  often  morphine  admin- 
istered. The  patients  are  then  transported  as  quickly  as  possible 
to  the  evacuation  hospital  or  a  special  hospital  (10  to  20  kilometers 
from  the  front),  where  most  of  the  serious  operations  are  performed. 
Here  the  wounds  are  again  re\dewed,  and  the  patients  sorted, 
some  going  to  the  evacuation  ward,  some,  after  preparation,  to 
the  operating  room,  and  the  badly  shocked  to  the  resuscitation 
ward.  The  character  of  the  operation  varies  with  the  structures 
injured.  In  this  place  we  shall  consider  merely  the  general  prin- 
ciples of  disinfection  and  suture,  reserving  for  the  chapters  on 
regional  surgery  the  description  of  the  measures  to  be  adopted  for 
special  lesions  of  special  parts. 

Mechanical  disinfection  {debridement)  is  indicated  in  all  shell 
and  shrapnel  wounds  and  in  all  lacerated  bullet  wounds.  The  clean 
smooth  perforation  resulting  from  an  undeformed  bullet  may  be 
treated  by  painting  the  skin  with  iodin  and  applying  sterile  gauze. 
Debridement  means  the  excision  of  the  wound  and  the  extraction  of 
all  foreign  bodies.  When  possible  metallic  foreign  bodies  should 
first  be  localized  by  the  X-ray.  The  skin  is  painted  with  iodin. 
The  wound  may  be  stained  with  iodin,  brilhant  green,  or  other 
antiseptic  dye,  in  order  to  make  its  excision  more  certain.  The 
orifice  of  entrance,  all  devitahzed  tissue,  detached  fragments  of  bone, 
and  foreign  bodies  (bullets,  shell  splinters,  pieces  of  clothing,  grass, 
etc.)  are  removed.     The  ends  of  a  fractured  bone  may  be  curetted 


CONirSlONS    AM)    \\()l  XDS  I49 

or  chiseled  away.  Complete  excision  of  the  wound,  however,  is  not 
always  possible  or  justifiable ;  large  blood  vessels  and  nerves  and  other 
important  structures  must  be  respected,  even  though  contaminated. 
After  making  sure  that  the  bleeding  has  been  controlled  the  wound 
may  be  closed,  or  left  ojjen  for  delayed  primary  or  for  secondary 
suture. 

Primary  suture  is  indicated  during  the  stage  of  contamination 
(i.e.  during  the  first  12  or  perhaps  24  hours)  if  all  the  damaged 
tissue  has  been  excised  and  the  bleeding  controlled,  the  bacterial 
smear  does  not  show  the  presence  of  streptococci,  and  if  the  patient 
can  be  watched  for  a  number  of  days  subsequently.  Wounds  of  the 
face  and  scalp  may  be  sutured  at  a  later  period  than  wounds  of  the 
lower  hmb  and  buttocks,  because  of  the  greater  danger  of  gas  gan- 
grene in  muscular  tissue. 

Delayed  primary  suture,  is  performed  within  a  few  days  of 
the  time  of  injury.  Incomplete  debridement,  or  the  presence  of 
streptococci  having  made  impossible  primary  suture,  the  wound  is 
dressed  aseptically  or  antiseptically,  and  cultures  are  made.  If  clin- 
ical evidences  of  infection  do  not  appear  and  bacteriologic  investiga- 
tion show^s  no  streptococci  or  Welch  bacilli,  even  though  there  are  a 
few  other  organisms  (one  in  two  fields),  the  wound  may  be  closed. 

Secondary  suture  is  applicable  after  an  infected  wound  has  been 
sterilized  by  the  Carrel-Dakin  method  or  other  form  of  treatment. 
The  time  for  closure  is  judged  by  the  healthy  appearance  of  the 
wound  and  by  the  bacteriologic  chart.  Smears  are  made  every  two 
days  and  a  culture  occasionally.  When  streptococci  are  absent, 
and  the  other  bacteria  in  three  successive  counts  are  few,  e.g.,  one  in 
two  microscopic  fields,  the  wound  is  closed.  The  line  of  ingrowing 
epithelium  is  excised,  and  the  skin  undermined  as  far  as  necessary  to 
permit  coaptation  without  undue  tension.  In  the  deeper  parts  it  may 
be  necessary  to  cut  away  dense  scar  tissue  and  granulations,  but,  if 
possible,  this  should  be  avoided,  because  of  the  danger  of  mobihzing 
latent  bacteria.  The  parts  are  sometimes  sutured  in  layers,  some- 
times brought  together  by  a  through-and-through  suture.  In  order 
to  facilitate  approximation  Dehelly  employs  ''corsetage"  of  the 
wound  for  48  hours  before  operation.  This  consists  in  the  applica- 
tion on  each  side  of  the  wound  of  adhesive  plaster,  along  the  edges 
of  which,  at  intervals,  are  hooks  which  are  laced  together  with  a 
rubber  string. 

Chemical  disinfection  during  the  war  followed  the  same  path 
as  antisepsis  in  civil  surgery.  At  first  strong  germicides  were 
employed,    then  less  harmful  substances,  and  finally   the   principle 


150  MANUAL    OF    SURGERY 

of  mechanical  sterilization,  with  asepsis,  grew  in  favor.  Reference 
to  hypochlorous  acid,  dichloramin-T,  the  germicidal  dyes,  and  to 
the  other  antiseptics  not  mentioned  below  will  be  found  in  chapter 
iii. 

The  Carrel-Dakin  method  consists,  first,  in  debridement,  partic- 
ular care  being  taken  to  tie  all  vessels  with  chromic  catgut.  The 
secondary  hemorrhages  which  may  follow  the  use  of  hypochlorite 
solutions  are  the  result  of  their  solvent  action  upon  the  devitalized 
and  infected  blood  vessel  walls  and  not  to  hemolytic  action  upon 
recent  thrombi  as  was  at  first  taught.  Dependent  drainage  is  pro- 
vided when  necessary;  the  counter  opening  is  made  at  the  most 
dependent  part  of  the  wound,  and  plugged  with  gauze  between 
the  daily  dressings,  since  one  of  the  principles  of  the  treatment 
is  to  retain  the  solution  in  contact  with  the  area  to  be  sterihzed. 
The  apparatus  consists  of  a  graduated  glass  reservoir  holding  one 
litre,  a  rubber  connecting  tube  running  from  the  reservoir  to  a 
glass  distributing  tube,  which  usually  has  four  short  branches 
to  which  are  attached  the  rubber  instillation  tubes,  which  convey 
the  fluid  to  the  wound.  The  reservoir  is  placed  one  metre  above 
the  wound.  On  the  connecting  tube  is  a  clamp  for  controlling  the 
flow  of  the  solution.  This  tube  and  the  glass  distributing  tube 
have  an  internal  diameter  of  7  mm.  The  instillation  tubes  are  25  cm. 
long,  tied  with  linen  at  the  ends,  have  an  internal  diameter  of  4  mm. 
and  lateral  perforations  i  mm.  in  diameter,  0.5  cm.  apart,  and 
staggered,  so  that  the  escaping  fluid  resembles  a  spray.  The  instil- 
lation tubes  are  so  arranged  that  every  portion  of  the  wound  receives 
some  of  the  solution.  A  superficial  wound  is  covered  with  a  single 
layer  of  gauze,  on  which  the  tubes  are  laid.  A  thick  layer  of  gauze 
on  the  wound  interferes  with  the  contact  between  the  solution  and 
the  raw  surface.  If  no  gauze  is  interposed  the  perforations  in  the 
tubes  may  be  closed  with  exudate.  In  a  penetrating  wound  a  single 
tube,  untied  and  without  lateral  perforations,  is  inserted,  so  that  the 
wound  is  filled  like  a  cup.  If  the  orifice  of  entrance  is  in  a  dependent 
position  the  tube  may  be  enveloped  with  toweling,  in  order  to  retain 
the  solution.  In  a  perforating  wound  the  lower  orifice  is  plugged  with 
gauze,  so  that  the  fluid  will  not  escape.  In  wounds  of  the  hand  and 
the  foot  the  part  may  be  soaked  in  the  solution  for  1 5  minutes  every 
two  hours.  In  all  cases  the  surrounding  skin  must  be  protected  with 
a  vaselinized  gauze.  Nonabsorbent  cotton  is  used  as  an  outer  dress- 
ing, since  it  does  not  withdraw  the  solution  from  the  wound.  The 
fluid  is  instilled  every  two  hours,  day  and  night,  by  unclamping  the 
connecting    tube    for   one  or  two  seconds.     The  quantity  of  fluid 


CONTUSIONS    AND    WOUNDS  I  SI 

allowed  to  escape  depends  on  the  size  of  the  wound,  but  averages 
about  lo  cc.  The  object  is  to  moisten,  not  to  irrigate,  the  wound. 
The  wound  is  dressed  once  daily,  when  the  tubes  and  gauze  are  re- 
newed, after  the  wound  has  been  flushed  with  Dakin's  solution  and 
scrubbed  with  sterile  soap  solution;  the  skin  being  cleansed  with 
soap-water  and  alcohol  before  the  vaselin  gauze  strips  are  applied. 
This  treatment  is  continued  until  the  wound  is  free  of  bacteria,  a 
smear  being  taken  every  second  day,  and  the  average  number  of 
bacteria  per  microscopic  field  recorded  on  a  chart,  which  resembles  a 
temperature  chart,  so  that  the  rise  and  fall  of  the  bacterial  curve  can 
be  seen  at  a  glance.  When  there  is  only  one  microbe  to  five  fields  the 
wound  is  regarded  as  clinically  sterile,  and  may  be  sutured.  Gener- 
ally the  microbes  make  their  appearance  about  the  tenth  hour, 
mount  in  numbers  for  two  or  three  days,  remain  stationary  for  a  few 
days,  and  then  decrease  progressively  when  treated  in  this  way. 
Wounds  of  the  soft  parts  are  sterilized  in  from  five  to  eight  days, 
fractures  in  from  two  to  four  weeks  (Lyle). 

M orison'' s  Bip  consists  of  bismuth  subnitrate  i.  iodoform  2,  and 
liquid  parafi&n  oil  i.  The  wound  is  cleansed  physically,  mopped 
with  alcohol,  dried,  and  the  paste  rubbed  in  with  gauze.  The  wound 
is  then  sutured.  If  too  much  of  the  paste  is  used  there  is  danger 
of  poisoning. 

The  physiologic  method  oj  Wright  is  based  upon  the  natural  de- 
fensive powers  of  the  tissues.  Wright  believes  that  antiseptics  are 
always  useless,  often  harmful.  After  surgical  disinfection  as  outlined 
above,  hypertonic  salt  solution  (5  per  cent.)  is  applied  by  continu- 
ous irrigation,  immersion,  wet  dressings,  or  by  packing  the  wound 
with  salt  tablets,  which  dissolve  in  the  wound  fluids.  The  salt 
produces  abundant  exudation  of  lymph,  which  is  laden  with  anti- 
bodies, and  has  antitryptic  properties,  thus  preventing  the  trypsin 
of  the  wound  secretion  from  digesting  the  proteins  of  the  lymph  and 
converting  them  into  suitable  food  for  the  bacteria.  This  "lymph 
lavage''  detaches  sloughs,  decreases  edema,  and  destroys  most  of 
the  serosaprophytes,  i.e.,  the  majority  of  bacteria,  which  do  not 
grow  in  normal  serum,  but  do  flourish  in  serum  tainted  with  dead 
leukocytes.  The  serophytes,  e.g.,  streptococci  and  staphylococci, 
grow  in  normal  serum,  hence  are  little  influenced.  As  the  hypertonic 
solution  hinders  the  migration  of  leukocytes  and  kills  those  which  do 
migrate,  thus  favoring  the  multiphcation  of  bacteria,  it  must  be 
replaced  by  the  isotonic  solution  as  soon  as  the  sloughs  have  been 
eliminated.  The  hypertonic  solution  is  lymphagogic,  the  isotonic 
leukocytagogic,  i.e.,  respects  the  leukocytes  and  draws  them  toward 


152  MANUAL    OF    SURGERY 

the  surface  where  they  may  attack  the  microbes.  When  the  wound 
is  sterile,  it  is  sutured.  Vaccins  of  the  strepto-  or  staphylococcus  are 
injected  as  soon  after  the  injury  as  possible.  Grey  recommends 
filling  the  wound  with  salt  sac  drains  each  of  "which  consists  of  a 
two-walled  sac  of  suitable  size  made  of  bandage,  between  the  layers  of 
which  four  layers  of  gauze  are  placed.  The  interior  of  the  sac  is 
filled  with  salt,  and  the  tail  of  the  bandage  forms  a  drain"  (Hull). 

The  Reading  bacillus  is  a  proteolytic  anaerobe  which  putrefies 
dead  tissue  and  destroys  the  toxins  of  other  bacteria.  Donaldson 
has  introduced  this  organism  into  wounds,  with  the  idea  of  driving 
out  pathogenic  microbes. 

Radiotherapy,  thermotherapy,  heliotherapy,  hyperemia  (active  or 
passive),  and  aeration  of  wounds  may  be  mentioned  among  the 
methods  that  have  been  suggested  or  employed  in  the  treatment  of 
war  wounds. 

Poisoned  wounds  are  contaminated  with  some  non-bacterial 
poison.  The  possibility  of  lockl  and  general  symptoms  from  the  use 
of  toxic  antiseptics  should  be  mentioned  in  this  connection.  Snake 
and  insect  bites  are  examples  from  the  animal  kingdom.  Among 
the  nonbacterial  vegetable  posions  that  may  enter  a  wound  are  curare 
and  other  plant  extracts  used  by  savages  to  poison  weapons  of 
warfare. 

It  is  customary  to  consider  under  this  heading  dissection  and 
post-mortem  wounds,  because  the  infection  to  which  they  give  rise 
was  at  one  time  thought  to  be  due  to  a  specific  virus  generated  in  the 
dead  body.  It  is  true  that  an  abrasion  may  become  inflamed  from 
the  irritation  of  injection  fluids  or  saprophytic  organisms,  but  the 
virulent  infections  are  produced  only  by  pyogenic  cocci,  which  are 
especially  numerous  in  septic  operations  on  the  living,  and  in  the 
body  a  few  hours  after  death;  hence  the  predisposition  of  students, 
surgeons,  butchers,  and  pathologists.  Wounds  acquired  in  the 
operating  room  rarely  become  infected,  because  of  the  frequent  use 
of  antiseptics;  in  the  dissecting  room,  wounds  are  apt  to  be  less  serious 
than  those  acquired  in  an  autopsy  on  a  body  into  which  no  antiseptic 
preservative  fluid  has  been  injected.  The  infection  varies  in  viru- 
lency  with  the  nature  and  number  of  the  bacteria  and  the  resistance 
of  the  individual,  being  most  frequent  in  those  who  are  "run  down." 
In  the  graver  forms  there  are  wide-spread  cellulitis,  lymphangitis, 
and  profound  toxemia,  which  may  result  fatally.  As  a  prophylactic 
measure  some  anoint  the  hands  with  sterile  vaselin,  but  much  more 
efficient  is  the  wearing  of  rubber  gloves.  If  a  wound  is  received, 
the  base  of  the  finger  should  be  compressed  with  a  bandage  or  with 


COXTUSIONS    AMJ    WOUNDS  1 53 

the  opposite  hand,  in  order  to  encourage  bleeding,  and  the  part 
washed  with  soap  and  water,  sucked  with  the  mouth,  and  disinfected 
with  bichlorid  of  mercury  solution,  i  to  500.  A  deep  and  narrow 
wound  should  be  incised  in  order  to  facilitate  disinfection.  The  part 
is  dressed  with  gauze  wet  in  bichlorid  solution,  and  at  the  first 
indication  of  infection  incision  and  redisinfection  should  be  practised. 

Insect  stings,  produced  by  hymenoptera,  such  as  bees,  wasps, 
hornets,  and  yellow  jackets,  cause  pain  and  swelling,  but  are  not  danger- 
ous unless  there  be  a  great  number,  unless  infection  occurs,  or  unless 
the  injuries  are  in  the  mouth  or  throat,  in  which  event  edema  of 
the  glottis  may  arise.  As  the  poison  is  acid  it  may  be  neutralized 
with  dilute  ammonia  water,  or  a  solution  of  bicarbonate  of  soda;  if 
there  be  much  swelhng,  ice,  or  lead-water  and  laudanum  may  be 
appHed.  The  wasp  has  a  pointed  sting  and  may  inflict  several 
injuries;  that  of  a  bee  is  barbed  and  remains  in  the  tissues,  from 
which  it  should  be  extracted  with  small  forceps,  after  being  made 
prominent  by  the  pressure  of  a  watch  key.  The  bites  of  flies,  fleas, 
gnats,  bedbugs,  and  mosquitoes  are  never  serious,  unless  the  insect 
is  soiled  with  some  form  of  infection  at  the  time  of  the  bite,  or  unless 
the  wound  is  subsequently  infected  by  scratching.  Special  mention, 
however,  should  be  made  of  the  role  played  by  insects  in  carrying 
disease.  The  domestic  fly  may  transmit  typhoid  fever  and  other 
maladies;  the  mosquito,  malaria,  yellow  fever,  filariasis,  and  dengue; 
rat  fleas,  plague;  Hce,  typhus  and  relapsing  fever;  the  tsetse  fly, 
sleeping  sickness;  bed  bugs,  kalaazar;  and  ticks.  Rocky  mountain 
spotted  fever.  Gad-flies  deposit  eggs  in  the  hides  of  animals,  but 
rarely  in  the  human  skin.  Ticks  (ixodes)  bury  themselves  in  the 
skin,  producing  great  annoyance,  sometimes  localized  suppuration, 
rarely  a  spreading  cellulitis.  Large  spiders,  including  the  tarantula 
and  the  scorpion,  may  cause  great  swelhng  and  serious  constitutional 
disturbances,  but  seldom  death.  Bites  by  the  more  poisonous  insects 
are  treated  by  placing  a  ligature  above  the  bitten  point,  incising  the 
bite  and  sucking  it,  washing  with  a  strong  solution  of  permanganate 
of  potassium,  or  cauterizing  with  silver  nitrate,  and  then  dressing 
antiseptically.  The  Hgature  is  gradually  loosened,  and  symptoms 
of  prostration  watched  for  and  treated,  if  they  appear,  by  alcohol 
and  other  stimulants. 

Snake  bites  are  harmless  unless  produced  by  venomous  snakes, 
the  varieties  of  which,  in  the  United  States,  are  the  rattlesnake, 
moccasin,  copperhead,  and  viper;  with  these  is  usually  classed  a 
poisonous  lizard,  the  Gila  monster.  The  venom  is  injected  from 
the  poison  sac  on  each  side  of  the  jaw,  through  the  hollow  fangs  of 


154  MANUAL    OF    SURGERY 

the  teeth,  into  the  wound;  it  is  a  sterile,  viscid,  yellowish,  acid  fluid, 
with  a  peculiar  odor,  and  contains  several  proteids,  a  peptone,  and  a 
globuhn,  all  of  which  are  toxic. 

The  character  of  the  symptoms  is  the  same  with  all  varieties  of 
venomous  snakes,  but  differs  in  degree  with  the  amount  and  virulence 
of  the  venom  and  the  resistance  of  the  individual.  The  bitten  part 
is  the  seat  of  great  pain  and  begins  to  swell  immediately.  As  the 
swelling  extends  ecchymotic  spots,  due  to  extravasated  blood,  are 
noticed,  and  symptoms  of  severe  prostration  appear,  sometimes  with 
vertigo,  convulsions,  delirium,  or  other  nervous  symptoms.  Snake 
venom  has  a  hemolytic  action  on  blood  cells,  and  dissolves  also  the 
endothelial  cells  of  the  capillaries,  thus  accounting  for  the  ecchymotic 
spots.  Death  may  occur  very  rapidly  if  the  poison  enters  a  vein,  or 
it  may  be  postponed  a  number  of  hours  or  even  days,  the  parts  being 
the  seat  of  a  spreading  cellulitis.     The  mortality  is  about  25  per  cent. 

The  treatment  is  to  constrict  the  hmb  tightly  by  a  ligature  above 
the  bite,  which  should  be  excised,  and  as  much  as  possible  of  the 
poison  removed  by  cupping,  or  sucking  and  squeezing.  The  wound 
should  then  be  cauterized,  preferably  with  the  actual  cautery,  and 
dressed  with  a  saturated  solution  of  permanganate  of  potassium. 
Constitutional  symptoms  are  met  by  stimulation  with  ammonia, 
alcohol,  strychnin,  and  digitalis.  When  the  symptoms  subside,  the 
ligature  is  cautiously  loosened,  and  if  they  reappear,  again  tightened 
and  further  stimulation  administered.  In  some  cases  amputation 
has  been  performed.  Calmette  believes  that  the  toxins  of  all  snake 
venom  are  the  same,  and  that  they  can  be  neutralized  by  the  same 
antitoxin.  This  antitoxin  (antivenene)  is  made  by  injecting  into  a 
horse  increasing  doses  of  the  mixed  venom  of  the  cobra,  80  per  cent., 
and  viper,  20  per  cent.  Other  observers  believe  each  species  of  snake 
has  a  specific  venom,  and  that  an  antitoxin  would  have  to  be  pre- 
pared for  each.  It  seems  certain,  however,  that  Calmette's  anti- 
venene is  effective  not  only  in  cobra  bites,  but  in  any  form  of  snake 
bite,  so  that  it  should  be  used  whenever  possible.  From  10  to  40  cc, 
are  injected  into  the  region  of  the  bite,  or  if  much  time  has  elapsed, 
directly  into  a  vein.  Calmette  advises  injections  into  and  around 
the  seat  of  inoculation,  also  of  from  20  to  30  cc.  of  a  fresh  i  per  cent, 
solution  of  chlorid  of  gold  and  calcium,  and,  after  removal  of  the 
ligature,  thorough  irrigation  of  the  part  with  a  solution  of  sodium 
hypochlorite  or  calcium  chlorid. 


CHAPTER  XI 

CHEMICAL,  THERMAL,  AND  ELECTRICAL  INJURIES 
BURNS  AND  SCALDS 

Burns  and  scalds  are  injuries  due  to  heat,  scalds  to  lluids  or  gases, 
burns  to  llames,  heated  sohd  bodies,  or  radiated  heat  (e.g.,  from  open 
fires  or  exposure  to  the  sun).  Injuries  due  to  chemical  substances, 
such  as  strong  acids  and  alkalies,  also  are  called  burns.  Burns  are 
divided  into  three  degrees:  (i)  Erythema  (combustio  erythematosa), 
the  best  example  of  which  is  sunburn,  is  accompanied  by  all  the 
signs  of  inflammation,  which  subside  in  a  few  days  and  are  followed 
by  brownish  discoloration  or  desquamation.  (2)  Bhstering  (com- 
bustio bullosa)  is  best  seen  after  scalds.  The  blisters,  or  vesicles, 
develop  at  once  or  not  for  several  days.  (3)  Charring,  carbonization, 
or  gangrene  (combustio  escharotica)  is  usually  due  to  direct  contact 
with  flames  or  heated  solids.  The  burned  part  is  hard,  anesthetic, 
and  yellowy  brown,  or  black,  being  surrounded  by  burns  of  the  first 
and  second  degrees.  The  dead  tissue  is  finally  separated  from  the 
living  by  ulceration.  Dupuytren's  classification  is  as  follows:  (i) 
Erythema;  (2)  blistering;  (3)  partial  destruction  of  the  skin;  (4) 
destruction  of  the  entire  skin;  (5)  destruction  of  the  subcutaneous 
tissues  and  part  of  the  muscles;  (6)  carbonization  of  the  entire  part. 

The  surgeon  should  bear  in  mind  the  danger  of  these  injuries 
when  using  hot-water  bags,  hot  douches,  and  the  hot-air  apparatus, 
and  the  danger  of  using  ether,  ethyl  chlorid,  or  collodion  near  a 
naked  flame  or  the  actual  cautery. 

The  symptoms  of  burns  and  scalds  may  be  studied  under  three 
headings:  (i)  Those  the  direct  result  of  the  injury;  (2)  those  occur- 
ring during  the  stage  of  inflammation  and  sloughing;  (3)  those  oc- 
curring during  the  stage  of  repair. 

1.  The  symptoms  of  the  first  stage  are  intense  pain,  and  shock 
varying  with  the  extent  and  severity  of  the  burn.  The  shock  in  this 
stage  is  Primary  Wound  Shock  and  follows  exhaustion  of  the  central 
nervous  system  and  radition  of  body  heat. 

2.  If  the  patient  survives  the  shock,  fever  develops,  due  at  first 
to  the  absorption  of  toxins  and  the  result  of  destruction  of  the  tissues, 
and  the  clinical  •  condition  of  Secondary  Toxic  Wound  Shock. 
Later  the  suppuration  which  follows,  is  accompanied  by  the  usual 


156  MANUAL    OF    SURGERY 

symptoms.  There  is  a  marked  leukocytosis  and  polycythemia,  and 
an  increase  in  the  coagulability  of  the  blood,  which  sometimes  leads 
to  extensive  thrombosis  and  subsequently  to  embolism.  The  internal 
organs  in  a  severe  burn  become  congested,  and  sometimes  inflamed. 
Congestion  of  the  brain  or  lungs  is  not  infrequent,  but  the  \'iscera 
most  apt  to  be  affected  are  the  kidneys,  giving  rise  to  albuminuria 
and  decreased  quantity  or  even  suppression  of  urine,  and  the  gastro- 
intestinal canal,  causing  vomiting  and  diarrhea,  and  later  ulceration, 
especially  in  the  duodenum  {Curling's  ulcer).  Ulceration  occurs  in 
the  duodenum  probably  because,  as  the  result  of  the  acid  gastric 
juice  being  squirted  against  the  mucous  membrane,  this  is  the  most 
irritated  spot  in  the  body,  and  the  first  to  break  down  when  the 
general  resistance  is  enfeebled  by  sepsis.  Curling's  ulcer  has  been 
attributed  also  to  the  toxin  laden  bile,  and  to  thrombosis  or  embol- 
ism; it  has  the  same  symptoms  and  treatment  as  ulcer  due  to  other 
causes.  Delirium  or  convulsions,  may  occur  from  congestion  of  the 
brain.  During  this  stage,  which  lasts  from  two  to  live  weeks  or 
longer,  there  is  active  suppuration  with  the  separation  of  sloughs. 

3.  During  the  stage  of  repair  there  may  be  no  constitutional 
symptoms  except,  perhaps,  weakness  or  anemia,  unless  the  wounds 
are  very  large  and  freely  suppurating,  when  there  will  be  some  fever 
(hectic),  and  possibly  amyloid  disease  if  the  suppuration  persists  for 
a  long  time. 

The  prognosis  depends  upon  the  age  and  general  condition  of  the 
patient,  and  the  extent,  depth,  and  location  of  the  burn.  In  the 
young,  the  old,  or  the  debilitated,  limited  burns  of  the  first  degree 
may  prove  fatal.  If  a  burn  of  the  first  degree  extends  over  more  than 
two-thirds  of  the  surface  of  the  body,  death  is  likely  to  follow.  The 
same  result  is  probable  in  a  burn  of  the  second  or  third  degree  involv- 
ing one-third  of  the  surface  of  the  body.  Burns  of  the  thorax  or 
abdomen  are  much  more  serious  than  those  of  the  limbs.  Death 
may  be  due  to  asphyxia  from  smoke  at  the  time  of  the  accident,  to 
shock  immediately  after  the  accident,  and  later  to  sepsis,  tetanus, 
exhaustion,  or  internal  complications.  Burns  of  the  third  degree  are 
always  followed  by  scars,  which,  when  extensive,  tend  strongly  to 
contract,  causing  flexures  of  joints,  ectropion,  ankylosis  of  the  jaw,  etc. 

Treatment. — A  person  whose  clothing  is  on  fire  should  be  thrown 
on  the  floor  and  rolled  in  a  rug,  overcoat,  shawl,  or  blanket,  in  order 
to  smother  the  flame;  water  should  not  be  used,  as  the  steam  will 
produce  scalding.  In  trivial  burns  of  the  first  or  second  degree  the 
principal  indication  is  to  relieve  the  pain;  this  is  best  done  by  the  use 
of  cold  lead-water  and  laudanum  or  aqua  hamamelidis,  the  applica- 


CHEMICAL,    THERMAL,    AND    ELECTRICAL    INJURIES  1 57 

tion  of  a  bandage  to  exclude  the  air,  and  by  elevation.  Ointments 
(zinc,  boracic,  vaselin,  lanolin)  are  soothing,  but  should  not  be 
usefl  unless  sterile,  and  if  applied  before  exposure  to  heat,  will 
protect  the  skin  from  burns  of  the  first  degree.  Blisters  may  be 
punctured  with  an  aseptic  needle,  allowing  the  epidermis  to  settle 
back  on  the  cutis  vera;  partly  detached  shreds,  however,  should 
be  removed  with  scissors.  Picric  acid  may  be  used  in  limited  burns 
of  the  lirst  and  second  degree,  but  not  in  extensive  or  deep  burns, 
as  poisoning  may  result.  Lint  or  gauze  is  soaked  in  a  i  per  cent, 
watery  solution  of  picric  acid  and  applied  to  the  burned  part, 
and  over  this  sterilized  cotton  or  gauze  is  bandaged.  The  dress- 
ing is  left  in  place  several  days.  Hull's  preparation  of  paraflSn  for 
the  treatment  of  burns  consists  of  resorcin  i,  oil  of  eucalyptus  2, 
olive  oil  5,  soft  paraffin  25,  hard  paraffin  67.  Instead  of  the  resorcin 
one  may  substitute  betanapthol  .25  per  cent,  and  increase  the  hard 
paraffin  to  67.75  P^'*  cent.  The  hard  paraffin  is  melted,  the  soft 
paraffin  and  olive  oil  added,  then  the  resorcin  after  being  dissolved 
in  absolute  alcohol,  and  finally  the  oil  of  eucalyptus.  The  prepara- 
tion when  it  is  to  be  used,  is  remelted  in  a  tin  in  a  water  bath.  The 
burn  is  washed  with  salt  solution  (Hull  now  uses  i  to  1000  profiavin.) 
dried  with  gauze  or  an  electric  drier,  and  coated  with  the  paraffin 
at  a  temperature  of  122  degrees  F.,  using  a  broad  camel's  hair  brush 
or  a  special  atomizer.  A  thin  layer  of  cotton  or  wool  is  laid  on  the 
film  of  paraffin,  a  second  coating  of  paraffin  apphed,  then  a  dressing 
of  wool  or  cotton  and  a  bandage.  The  w^ax,  cotton  and  all  utensils 
should  be  sterile  and  applied  with  aseptic  surgical  technic.  The 
paraffin  film  is  removed,  the  burn  cleansed,  and  the  paraffin  reap- 
pHed  every  day.  The  paraffin  treatment  of  burns  has  the  same 
virtues  and  defects  as  the  ointment  treatment.  As  it  prevents 
drainage  we  believe  it  is  contraindicated  in  burns  of  the  third  degree, 
those  containing  dead  tissue  or  when  the  wound  is  not  surgically 
sterile. 

In  severe  burns  the  indications  are,  in  the^r^^  stage,  to  relieve  pain 
by  the  hypodermatic  injection  of  morphin  and  to  give  the  usual 
treatment  for  primary  wound  shock.  No  attempt  should  be  made 
to  dress  the  burn  until  reaction  has  been  obtained.  In  the  second 
stage  the  indications  are  to  prevent  or,  as  this  is  rarely  possible,  to 
limit  infection,  to  combat  the  toxemia,  and  to  watch  for  and  treat 
the  complications.  The  clothing  should  be  cut,  and,  if  it  sticks, 
soaked  in  sterile  sweet  oil  or  salt  solution  and  allowed  to  drop  off. 
The  dressing  of  one  part  should  be  completed  before  exposing  an 
additional  area.     If  there  is  much  charred  tissue,  the  patient  may 


158  MAXUAL    OF    SURGERY 

be  anesthetized  and  the  devitaHzed  parts  cut  away.  The  ideal 
dressing  would  be  aseptic  or  mildly  antiseptic,  would  provide  free 
drainage,  would  not  macerate  or  stick  to  the  tissues,  and  would  not 
necessitate  frequent  changing.  Unfortunately  it  does  not  exist. 
Wet  dressings  macerate,  dry  dressings  stick  to  the  tissues,  and  oint- 
ments have  the  same  objections  here  as  in  the  treatment  of  ulcers, 
although,  it  must  be  confessed,  they  are  often  employed  because 
they  are  comforting  to  the  patient.  If  an  ointment  is  used  it  must  be 
sterile  and  holes  should  be  cut  in  the  hnt  to  faciUtate  drainage.  The 
first  three  of  the  following  methods  come  as  near  the  ideal  as  any. 
When  the  burn  is  not  too  large  the  dressing  advised  for  spHnting 
skin  grafts  (see  "  Skin  Grafting  ")  may  be  employed.  ]\Iore  extensive 
burns  may  be  dressed  with  strips  of  steriUzed  rubber  tissue  about  an 
inch  broad,  allowing  a  fourth  inch  between  each  strip,  and  placing 
over  this  sterile  gauze  which  has  been  wrung  out  in  warm,  sterile, 
salt  solution.  The  gauze  is  changed  as  often  as  it  becomes  saturated 
with  discharges,  leaving  the  rubber  tissue  in  place,  thus  ehminating 
much  of  the  pain  and  distress  which  is  always  an  unpleasant  feature 
in  the  dressing  of  these  cases.  When  most  of  the  body  is  burned  the 
patient  may  be  kept  in  a  warm  bath  (100°  to  105°).  One  of  the 
most  efficient  and  least  painful  methods  of  removing  the  dressing  is 
by  a  daily  immersion  of  a  half  hour  or  more  in  a  2  per  cent,  solu- 
tion of  sodium  bicarbonate.  Lee  has  obtained  excellent  results  by 
spraying  \A-ith  a  0.5  per  cent,  solution  of  dichloramin-T,  applying  a 
single  layer  of  wide-meshed  paraffined  gauze,  and  exposing  the  part 
to  the  air  and  an  electric  hght  bath.  Carron  oil  (equal  parts  of 
hnseed  oil  and  hme-water),  to  which  oil  of  eucalyptus  in  the  pro- 
portion of  I  to  10  has  been  added  for  its  antiseptic  properties,  is  a 
favorite  appKcation  but  is  not  to  be  recommended.  ]\Ienthol  i, 
oHve  oil  9,  and  hme-water  10,  has  been  recommended  as  an  anti- 
septic and  analgesic;  a  saturated  solution  of  bicarbonate  of  soda  or 
of  boric  acid  also  may  be  employed.  Satisfactory  results  have 
been  obtained  by  exposing  burns  to  the  air  and  simply  dusting 
them  with  stearate  of  zinc,  removing  scabs  when  pus  collects  be- 
neath them.  Because  of  their  poisonous  properties,  dressings  con- 
taining acetanihd,  antipyrin,  carbohc  acid,  carbonate  of  lead,  cocain, 
creoHn,  iodoform,  phenol  sodique,  picric  acid,  or  lead-water  and 
laudanum,  should  not  be  used  on  extensive  burns.  If  a  limb  has  been 
completely  carbonized,  amputation  should  be  performed  as  soon  as 
shock  has  subsided.  The  toxemia  is  combated  by  giving  concen- 
trated hquid  food,  and  plenty  of  water,  by  mouth  or  rectum,  or, 
if  need  be,  subcutaneously  or  intravenously;  and  by  administering 


CHEMICAL,    THERMAL,    AND    ELECTRICAL    INJURIES  1 59 

stimulants  as  may  be  required.  Comi)lications  should  be  met 
according  to  general  indications.  In  the  third  stage  the  indications 
are  to  promote  healing  and  prevent  contractures.  It  may  become 
necessary  to  use  stimulating  applications  or  to  remove  prominent 
granulations,  as  described  in  the  chapter  on  "Ulceration."  Corset- 
age  (see  "  Gunshot  Wounds"),  and  excision  with  subsequent  suturing 
is  applicable  in  suitable  cases.  In  an  extensive  granulating  wound 
skin  grafting  not  only  hastens  cicatrization,  but  hmits  subsequent 
contraction.  For  the  latter  purpose  spHnts  should  be  used  in  burns 
about  joints,  and  opposed  burned  surfaces,  e.g.,  of  the  lingers,  should 
be  separated  with  dressings.  After  the  scar  has  formed,  exercises, 
massage,  and  systematic  stretching  may  be  of  service  in  lessening  the 
tendency  toward  contraction. 

In  burns  by  acids,  a  weak  alkali,  such  as  lime-water,  and  in  burns 
by  alkalies,  a  weak  acid,  such  as  a  dilute  solution  of  acetic  acid, 
should  be  applied.  In  carbohc  acid  burns  alcohol,  if  applied  at 
once,  will  act  as  a  neutralizing  agent.  Yellow  phosphorus  sticks  to 
and  burrows  into  the  skin,  and  bursts  into  flame  on  being  exposed  to 
the  air;  the  part  should  be  put  under  cold  water,  to  which  should  be 
added  a  solution  of  chlorid  of  iron,  or  liquor  sodae  chlorinatae.  Burns 
of  the  mouth,  pharynx,  glottis,  and  esophagus  are  usually  produced  by 
chemicals,  although  the  accident  may  occur  from  boiHng  fluid  or 
superheated  steam.  These  cases  are  treated  by  having  the  patient 
suck  bits  of  ice,  by  the  application  of  ice  externally,  and  in  a  burn  of 
the  mouth  by  antiseptic  washes.  One  should  watch  for  signs  of  edema 
of  the  glottis  (q.v.).  In  burns  of  the  esophagus  the  chemical  should 
be  neutralized,  and  the  patient  fed  on  albumin  water  or  by  rectum; 
the  danger  of  passing  a  stomach  tube  should  be  recalled.  In  two  or 
three  weeks  bougies  should  be  cautiously  passed,  in  order  to  antici- 
pate the  formation  of  a  stricture. 

X-ray  bums  (see  chapter  I). 

THE  EFFECTS  OF  COLD 

Locally,  cold  contracts  the  blood  vessels  ajid,  when  intense, 
causes  thrombosis  and  disorganization  of  the  blood.  According  to 
the  changes  which  follow,  frost  bite,  like  burns,  may  be  divided  into 
three  degrees:  (i)  Erythema,  or  redness;  (2)  bhstering,  or  bleb 
formation;  (3)  sloughing,  or  gangrene. 

The  symptoms  of  freezing  are  first  coldness,  then  numbness,  and 
finally  anesthesia;  owing  to  the  contraction  of  the  vessels  the  parts 
become  deathly  pale.     In  frost  bites  of  the  first  degree  the  parts, 


l6o  MANUAL    OF    SURGERY 

when  warmed,  are  the  seat  of  burning,  itching,  or  tingling  pain,  and 
become  red  and  swollen,  due  to  the  overfilling  of  the  paretic  blood 
vessels.  This  inflammation  disappears  in  the  course  ol  a  few  days,  but 
may  recur  on  slight  exposure  to  heat  or  cold  {chilblain,  or  pernio),  and 
is  most  frequent  in  the  toes,  ears,  fingers,  and  nose.  Chilblains  itch 
and  burn  and  sometimes  ulcerate.  In  frost  bites  of  the  second  degree, 
reaction  is  attended  with  greater  swelling,  a  livid  color,  and  the 
formation  of  blisters,  or  blebs.  In  the  majority  of  these  cases  frost 
bite  of  the  third  degree,  or  gangrene,  occurs.  Gangrene  is  due  to  the 
direct  eft"ect  of  cold  or  to  the  reactionary  inflammation.  In  the 
former  instance  thrombosis  occurs  and  the  tissues  become  pale, 
anesthetic,  and  brittle;  fingers  and  toes  may  break  like  glass.  As 
the  blood  cannot  again  enter  the  vessels,  the  part  undergoes  the 
changes  incident  to  dry  gangrene.  In  gangrene  due  to  inflamma- 
tory reaction  the  vessels  are  obliterated  chiefly  by  the  pressure  of 
the  exudate ;  owing  to  the  large  amount  of  fluid  in  the  tissues,  the 
gangrene  is  of  the  moist  variety. 

The  treatment  oi  frost  bite  is  the  gradual  restoration  of  circulation, 
so  that  the  vessels  may  have  a  chance  to  recover  their  tone  before  a 
large  amount  of  blood  enters  the  part.  The  frosted  area  should  first 
be  rubbed  with  ice  water  or  snow;  as  thvj  circulation  is  restored,  it 
may  be  very  gradually  warmed  by  omitting  the  snow  and  using  only 
the  hand.  The  temperature  of  the  room  should  be  slowly  elevated, 
and  the  part  wrapped  in  cotton.  When  marked  inflammatory  reac- 
tion follows,  free  incisions  should  be  made  to  relieve  tension.  If 
gangrene  occurs,  wait  for  the  line  of  demarcation  and  amputate, 
unless  it  be  moist,  septic,  and  rapidly  progressing,  when  immediate 
amputation  becomes  mandatory. 

Chilblains  are  treated  by  attention  to  the  general  health,  which  is 
often  below  par,  and  by  warm  coverings  at  the  first  approach  of  cold 
weather.  The  part  may  be  rubbed  with  alcohol  and  water,  bella- 
donna liniment,  whisky  and  salt,  soap  Hniment,  or  menthol  and 
ohve  oil  I  to  lo;  or  tincture  of  iodin,  ichthyol,  contractile  collodion, 
adhesive  plaster,  or  diachylon  may  be  apphed.  ]\Iassage  is  often 
useful.     When  ulcers  form  they  should  be  treated  antiseptically. 

Trench  foot,  so  common  during  the  war,  is  due  to  ischemia, 
induced  by  wet.  cold,  tight  foot  gear,  standing  still,  and  crouching. 
According  to  Raymond  and  Pariot  the  condition  is  a  mycosis,  caused 
by  fungi,  of  which  they  have  isolated  three  varieties,  the  scopulariop- 
sis  koningii,  sterigmatocystis  versicolor,  and  penicillium  glaucum. 
The  same  authors  divide  the  disease  into  four  stages,  one  or  more  of 
which  may  be  traversed,   slowly  or  rapidly,  in  a  given  case:  (i) 


CHEMICAL,    THERMAL,    AND    ELECTRICAL    INJURIES  l6l 

Painful  anesthesia  or  paresthesia;  (2)  edema,  soft,  white,  cold,  occa- 
sionally red  or  bluish;  (^^)  blisters  on  the  dorsum,  containing  a  gela- 
tinous material,  which  on  bursting  give  rise  to  ulcers;  (4)  necrosis, 
which  may  be  superficial  (sloughs)  or  deep  (dry  or  moist  gangrene). 
The  general  symptoms  in  "3"  and  "4"  may  be  those  of  sepsis. 
The  complications  are  tetanus,  gas  gangrene,  lymphangitis.  Pro- 
phylaxis consists  in  greasing  the  feet,  as  grease  is  a  bad  conductor  of 
cold  and  water,  and  the  massage  attending  the  inunction  improves 
the  circulation;  exercise;  and  avoiding  tight  puttees  and  boots. 
Keeping  the  feet  dry,  warm,  and  clean  are  preventive  measures 
which,  for  a  soldier  in  a  trench  or  a  shell  hole,  may  be  impossible  of 
execution.  The  treatment  in  the  early  stages  is  that  of  frost  bite. 
Blisters,  ulcers,  and  gangrene  are  dealt  with  as  are  similar  lesions 
due  to  heat  or  cold.  Sweet,  Norris,  and  Wilmer,  who  believe  trench 
feet  are  the  result  of  spasm  of  the  arterioles,  advise  giving  potassium 
iodid  gr.  xx  t.d. 

The  constitutional  effects  of  cold  are  drowsiness,  slowing  of  the 
pulse  and  respirations,  and  dilatation  of  the  pupils.  The  blood  is 
driven  from  the  surface  to  the  internal  organs,  which  become  mark- 
edly congested.  Death  is  probably  due  to  cerebral  anemia  from 
failure  of  the  circulation.  The  treatment  of  freezing  of  the  whole 
body  is  brisk  rubbings  with  cold  cloths,  and  afterwards  with  the 
warm  hands.  The  patient  should  first  be.taken  into  a  cool  room,  the 
temperature  of  which  is  very  gradually  elevated,  as  sudden  reaction 
may  result  in  embolism,  or  in  rupture  of  blood  vessels,  especially 
those  of  the  brain.  Artificial  respiration  may  be  needed,  and 
stimulation  should  be  given  hypodermatically,  or  by  mouth  as  soon 
as  the  patient  is  able  to  swallow.  The  extremities  should  be  elevated 
in  order  to  limit  gangrene. 

INJURIES  BY  ELECTRICITY 

Lightning  stroke  is  produced  by  an  aerial  current  of  electricity. 
A  person  may  be  struck  directly  by  the  primary  current,  or  injured 
by  an  induced  current  when  the  lightning  strikes  some  neighboring 
object.  The  accident  is  most  frequent  in  the  open  country,  where 
there  are  few  buildings,  trees,  etc.,  to  divide  the  current.  The 
mortaHty  is  about  50  per  cent.  Lightning  either  kills  directly  or 
causes  severe  burns  or  extensive  lacerations,  sometimes  tearing  a 
lim.b  completely  from  the  body.  Lightning  marks  are  brownish-red, 
zigzag,  or  arborescent  fines,  radiating  from  the  point  struck  along  the 
course  of  blood  vessels,  and  are  due  to  the  decomposition  of  the  red 


l62  MANUAL    OF    SURGERY 

corpuscles,  with  the  subsequent  transudation  of  the  coloring  matter 
through  the  vessel  walls. 

The  S3miptoins  in  a  case  not  immediately  fatal  are  those  of  pro- 
found shock  and  compression  of  the  brain.  \'ariou5  nervous  dis- 
turbances, such  as  paralysis,  anesthesia,  blindness,  insanity,  hysteria, 
may  be  seen.  Excepting  lesions  due  to  hemorrhage  into  the  brain  or 
spinal  cord,  these  phenomena  usually  disappear  after  a  greater  or 
lesser  internal. 

The  treatment  is  symptomatic;  first  of  all  it  is  necessary  to  treat 
the  shock.  It  is  important  to  remember  here,  as  in  opium  poisoning 
and  drowning,  that  a  person  may  be  apparently  dead,  and  yet  be 
revived  by  prolonged  artificial  respiration.  When  reaction  has  been 
obtained,  the  patient  should  be  carefully  examined  for  fractures, 
lacerations,  and  burns.  Burns  are  often  slow  in  healing,  probably 
ouang  to  the  effect  of  the  electricity  on  the  trophic  ners'es;  the  treat- 
ment is  that  of  burns  from  other  causes.  The  effects  of  artificial 
currents  are  similar  to  those  of  hghtning  and  are  treated  in  the  same 
way.  When  a  person  is  ensnared  with  a  live  wire,  the  current  should 
be  turned  oft;  if  this  is  not  possible,  the  wire  may  be  removed  with  thick 
rubber  gloves,  mackintosh,  thick  and  dry  wollen  cloth,  or  dry  wood, 
or  occasionally  the  current  may  be  short  circuited  by  dropping  some 
object,  such  as  an  iron  bar.  on  the  two  wires,  or  grounded  in  the 
same  wav  when  there  is  one  wire. 


CHAPTER  XI r 

GENERAL  CONDITIONS  AND  SPECIAL  INFECTIONS 
FOLLOWING  WOUNDS 

SHOCK 

Shock  is  a  sudden  general  prostration  of  the  vital  powers  the 
result  of  injury,  emotion,  or  toxemia.  Local  shock  is  numbness  or 
anesthesia  of  a  part  which  has  been  injured,  and  is  seen  most  fre- 
quently in  contusions  and  contused  wounds.  Syncope  is  sudden 
transient  unconsciousness  from  temporary  suspension  of  the  heart's 
action.  Collapse  exhibits  the  features  of  extreme,  hyperacute 
shock,  and  is  due  to  many  causes.  Exhaustion  presents  similar 
symptoms  to  shock,  but  comes  on  gradually,  in  consequence  of 
fatigue,  starvation,  loss  of  sleep,  worry,  or  some  exhausting  disease, 
such  as  carcinoma  or  tuberculosis. 

Shock  of  nervous  origin  is,  according  to  Crile,  caused  by 
afferent  impulses  transmitted  along  the  sensory  or  sympathetic 
nerves,  or  in  emotional  shock  along  the  nerves  of  special  sense,  to  the 
vital  centers,  especially  the  vaso-motor  centers,  which  are  thus 
weakened  or  exhausted  (shock),  or  paralyzed  (collapse).  Quenu 
believes  that  a  toxaemia  resulting  from  the  absorption  of  albu- 
minoid poisons  developed  in  injured  tissues  is  one  of  the  causes  of 
shock.  Cannon  and  Bayliss  have  produced  such  symptoms  by 
crushing  tissues  and  have  proved  their  dependence  upon  the  circu- 
lation by  the  use  of  a  tourniquet.  The  sudden  development  of 
shock  after  the  removal  of  a  tourniquet  w^as  a  frequent  observation 
during  the  war.  Abel  has  found  a  substance  histamin  more  or  less 
constantly  in  crushed  tissues,  and  Dale  and  Richards  have  experi- 
mentally produced  the  symptoms  of  shock  by  intravenous  injections 
of  histamin.  As  a  result  of  the  changes  in  the  ganglion  cells  (Crile)^ 
or  the  toxic  action  of  chemical  substances  similar  to  histamin, 
there  are  marked  lowering  of  the  blood  pressure,  weakening  of  the 
propelling  force  of  the  heart  and  arteries,  collection  of  the  blood  in 
the  capillaries  and  anemia  of  the  brain,  lungs,  and  superficial  parts 
of  the  body.  In  the  veins  the  number  of  red  cells  and  the  amount 
of  hemoglobin  are  normal;  in  the  capillaries,  above  normal.  The 
blood  decreases  in  alkalinity  (acidosis),  increases  in  viscosity  (Can- 
non. Fraser,  Hooper). 

163 


164  MANUAL    OF    SURGERY 

The  symptoms  vary  in  intensity  according  to  the  severity  and 
situation  of  the  injury,  the  physical  condition,  age,  sex  (women  are 
more  susceptible),  and  previous  general  condition  of  the  patient,  and 
according  to  various  other  factors,  such  as  hemorrhage,  exposure  to 
cold,  etc.  In  torpid  or  apathetic  shock  there  are  marked  pallor  of  the 
skin  and  mucous  membranes,  cold  clammy  perspiration,  elongated, 
pinched,  expressionless  face,  half  open  mouth,  half  closed  shrunken 
eyes,  lusterless  cornea,  dilated  pupils  reacting  slowly  to  light,  weak 
and  rapid  pulse,  accelerated  (occasionally  slow)  shallow  and  irregular 
respirations,  mental  apathy,  subnormal  temperature,  impaired 
sensation  of  the  skin,  retention  of  urine,  and  sometimes  incontinence 
of  feces.  If  the  shock  is  due  to  or  aggravated  by  hemorrhage,  there 
may  be  a  great  restlessness  and  other  symptoms  commonly  asso- 
ciated with  the  loss  of  a  large  quantity  of  blood.  During  the  period 
of  reaction  there  may  be  vomiting,  great  restlessness  or  excitement, 
and  even  delirium  (erethistic  shock),  particularly  in  conditions  like 
extensive  burns,  in  which  a  toxic  factor  is  added.  Shock  which  does 
not  appear  for  several  hours  (delayed  or  secondary  shock)  is  most 
frequently  seen  after  railway  accidents,  alcoholic  intoxication,  and 
severe  emotional  storms.  After  operation  delayed  shock  is  almost 
always  due  to  hemorrhage. 

The  symptoms  of  hemorrhage  are  practically  identical  with  those 
of  shock,  in  fact  the  condition  after  hemorrhage  is  shock  due  to 
actual  loss  of  blood.  In  nervous  or  toxic  shock  the  circulatory 
failure  is  due  to  a  relative  loss  of  blood  volume,  the  fluid  elements 
passing  through  the  vessel  walls  into  the  tissues.  In  concealed 
hemorrhage  one  does  not  see  the  blood,  and  the  question  is  whether 
the  shock  arises  from  hemorrhage.  In  shock  caused  by  hemorrhage 
there  is  apt  to  be  greater  restlessness,  and  instead  of  torpidity,  great 
anxiety  and  foreboding  on  the  part  of  the  patient,  who  complains  of 
loss  of  sight,  asks  for  water,  and  gasps  for  air;  the  skin  and  mucous 
membranes  are  excessively  pale,  and  the  pulse,  although  very 
frequent,  is  likely  to  be  larger  and  more  compressible  than  that  of 
shock.  The  hemoglobin  is  greatly  lessened  in  hemorrhage  (but  not 
for  a  number  of  hours)  and  unreduced  in  shock.  The  most  rehable 
signs  are  those  of  fluid  in  a  cavity,  i.e.,  in  the  chest  or  abdomen. 
In  case  of  doubt,  especially  after  an  abdominal  operation  or  injury, 
an  exploratory  incision  should  be  made. 

The  prophylaxis  of  shock  is  possible  in  surgical  operations.  In 
addition  to  reassuring  a  nervous  patient,  the  physical  condition 
should  be  improved  as  much  as  possible.  Morphin  may  be  given 
for  pain,  bicarbonate  of  soda  for  acidosis,  blood  transfused  for  grave 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 65 

anemia,  and  external  heat.  With  the  patient  in  poor  comU- 
tion  shock  may  be  anticipated  by  blood  transfusion,  the  ap- 
plication of  hot  water  bags,  the  hypodermatic  injection  of 
strychnin  and  atropin,  the  careful  covering  of  the  patient  during 
operation,  the  avoidance  of  excessive  purgation  and  prolonged 
abstention  from  food  before  operation,  and  by  celerity,  gentleness, 
and  careful  hemostasis  during  the  operation.  The  part  to  be  oper- 
ated upon  may  be  placed  in  a  slightly  higher  position  than  the  rest 
of  the  body  in  order  to  lessen  hemorrhage.  The  use  of  a  local  anes- 
thetic for  the  prevention  of  shock  in  extensive  operations  is  of  doubt- 
ful value,  as  the  fright  of  the  patient,  and  the  increased  time  neces- 
sary for  the  performance  of  the  operation,  owing  to  the  struggles  of 
the  patient,  more  than  counter  balance  any  depressing  influence  of  a 
general  anesthetic.  In  head  operations  Crile  applies  a  temporary 
clamp  to  the  carotid,  places  the  patient  in  a  pneumatic  rubber  suit, 
and  elevates  the  upper  part  of  the  body  45°.  In  operations  on  the 
dangerous  area  of  the  larynx,  in  which  sudden  collapse  may  follow 
from  reflex  inhibition  of  the  heart  and  respiration  as  the  result  of 
stimulation  of  the  superior  laryngeal  nerve,  he  advises  a  preliminary 
dose  of  atropin,  or  the  application  of  cocain  to  the  nerve  endings  in 
the  larynx;  in  the  extremities  he  blocks  the  nerve  trunks  by  injecting 
into  them  procain,  one-half  per  cent. 

The  treatment  of  shock  consists  in  raising  the  feet  and  lowering 
the  head;  the  application  of  carefully  protected  hot  water  bags; 
the  hypodermatic  injection  of  ether  i  5 ,  brandy  i  5 ,  strychnin  gr. 
}io,  digitahn  gr.  Vfo,  atropin  gr.  lioo,  ergotin  vji,  Hoo,  pituitrin  30m, 
or  camphorated  oil  i  5  ;  inhalations  of  ammonia,  alcohol,  or  oxygen; 
the  rectal  injection  (enteroclysis)  of  hot  coffee  i  pint,  or  whisky 
I  ounce  with  warm  water  i  pint;  transfusion  of  blood;  hypoder- 
moclysis,  or  intravenous  infusion  (chap.  XV)  of  one-half  to  one  pint 
of  normal  salt  solution,  containing  respectively  from  one-half  to 
one  dram  of  adrenal  chlorid  solution  (i  to  1000).  As  normal  salt 
solution  leaks  quickly  from  the  vascular  apparatus,  in  its  stead  has 
been  suggested  hypertonic  salt  solution  (2  per  cent.),  sodium  bicar- 
bonate (4  per  cent.),  glucose  (6  per  cent.),  and  gum  acacia  6  per  cent, 
in  a  2  per  cent,  solution  of  sodium  bicarbonate,  but  we  have  hesitated 
to  employ  these  substitutes,  without  fuller  assurance  as  to  their  harm- 
lessness.  Autotransfusion  is  the  application  of  bandages  to  the  ex- 
tremities for  the  purpose  of  driving  the  blood  to  the  vital  centers.  If 
the  respirations  fail  despite  stimulation,  artificial  respiration  should  be 
performed.  Massage  of  the  heart  (chap.  XV)  has  been  employed  in 
a  few  cases.     Operations  are  not,  as  a  rule,  performed  during  the 


1 66  MANUAL    OF    SURGERY 

presence  of  shock,  unless  it  is  known  that  the  shock  is  being  increased 
by  the  condition  for  which  the  operation  would  be  performed,  e.g.. 
hemorrhage,  perforation  of  a  hollow  viscus,  and  some  cases  of  crushed 
extremities. 

AUTOINTOXICATION 

Autointoxication  usually  means  that  form  of  toxemia  resulting 
from  the  absorption  of  putrefying  intestinal  contents,  but  includes 
also  many  other  varieties  of  intoxication,  such  as  those  due  to  defi- 
cient elimination  from  the  kidneys  and  other  excretory  organs,  to  the 
absorption  of  disintegrating  portions  of  the  body  when  sterile  (aseptic 
wound  fever),  and  to  interference  wdth  glands  like  the  thyroid. 
]Most  of  the  autointoxications  are  strictly  medical,  but  are  of  great 
interest  to  the  surgeon  because  of  the  frequency  with  which  they 
complicate  surgical  conditions.  In  order  to  prevent  autointoxication, 
the  excretory  organs  should  receive  proper  investigation  and  care. 

Traumatic  diabetes  may  follow  injuries  and  operations,  involving 
not  only  the  brain,  spinal  cord,  liver,  pancreas,  and  kidney,  but  also 
other  organs  and  parts.  It  generally  appears  within  a  day  or  two  and 
is  transient,  seldom  leading  to  serious  consequences. 

The  only  other  autointoxication  with  which  we  shall  deal  here  is 
aseptic  fever. 

Aseptic  fever  (reactionary,  or  resorption  fever)  is  seen  after  sub- 
cutaneous injuries,  such  as  contusions,  fractures,  and  sprains,  and 
after  aseptic  operations.  It  is  due  to  the  absorption  of  sterile  prod- 
ucts of  cellular  disintegration,  chiefly  fibrin  ferment,  from  extra va- 
sated  blood  or  from  exudate,  hence  is  apt  to  be  of  greater  degree  after 
the  use  of  strong  antiseptics.  The  only  symptom  is  a  slight  rise  in 
temperature,  rarely  more  than  ioi°  F.,  which  disappears  by  the  end 
of  the  second  or  third  day.  If  the  fever  persists  beyond  this  time, 
especially  if  other  symptoms  appear,  it  is  almost  surely  due  to  some 
other  cause,  most  Ukely  infection  of  the  wound.  The  erythematous 
and  urticarial  rashes  which  are  sometimes  described  in  connection 
with  this  condition  are  probably  due  to  intestinal  derangement,  as 
they  subside  after  the  bowels  have  been  freely  evacuated.  Aseptic 
fever  requires  no  treatment. 

SEPSIS 

Sepsis,  or  "blood  poisoning."  includes  sapremia.  septic  intoxica- 
tion, septicemia,  and  pyemia.  The  former  two  are  due  to  the 
presence  of  toxins  alone  in  the  blood  (toxemia),  the  latter  two  to  the 
presence   of   toxins   and   bacteria    (bacteremia).     These   toxins   and 


GENERAL    CONDITKWS    AND    SPECIAL    INFECTIONS  1 67 

organisms  may  bo  of  any  variety,  l)ut  in  the  following  paragraphs 
septic  intoxication  and  septicemia  are  defmetl  in  their  restricted 
sense  as  referring  to  pyogenic  toxins  and  pyogenic  bacteria. 

Sapremia  is  due  to  the  absorption  of  the  products  of  putrefaction; 
hence,  properly  speaking,  autointoxication  from  decomposing  intes- 
tinal contents  is  sapremia.  Saprophytic  organisms  are  rarely  found 
alone  in  surgical  affections,  consequently  a  pure  form  of  sapremia  is 
rarelv  seen.  The  best  example  is  that  due  to  the  absorption  of 
more  or  less  ptomains  from  a  decomposing  placenta  after  child  birth, 
although  a  pure  form  may  be  seen  as  the  result  of  putrefaction  of 
blood  clots,  wound  secretions,  or  large  tumors.  Since  sapremia  is 
so  frequently  linked  with  other  septic  processes,  and  is  clinically  in- 
distinguishable from  septic  intoxication,  the  term  should  be  discarded. 

Septic  intoxication  {pyogenic  toxemia)  is  due  to  the  absorption  of 
pyogenic  toxins.  The  usual  cause  is  pus  under  pressure,  e.g.,  an 
unopened  abscess  or  a  badly  drained,  suppurating  wound.  As 
granulation  tissue  blocks  lymphatic  spaces,  toxins  are  not  readily 
absorbed  from  its  surface,  unless  pressure  be  added;  thus  in  a  com- 
pletely drained  abscess  there  are  no  constitutional  symptoms.  If  the 
drainage  be  defective,  however,  or  if  the  lymph  spaces  be  opend  by 
curettage,  absorption  takes  place.  Chronic  septic  intoxication  is 
hectic  fever. 

The  symptoms,  if  there  is  a  wound,  appear  usually  in  from  one  to 
three  days  after  the  injury,  and  vary  in  degree  according  to  the 
character  and  virulency  of  the  toxin,  the  amount  of  absorption,  and 
the  resistance  of  the  individual.  They  manifest  themselves  as 
fever  or  pyrexia^  which  is  a  syndrome  characterized  by  a  rise  in  tem- 
perature (often  preceded  by  a  chill),  quickening  of  the  pulse  and 
respirations,  headache,  backache,  diffuse  muscular  soreness,  general 
weakness;  by  disordered  secretions,  causing  dryness  of  the  mouth, 
coating  of  the  tongue,  thirst,  impaired  appetite  (sometimes  vomit- 
ing), constipation  or  diarrhea,  scanty  high  colored  urine  containing 
an  excess  of  urea  and  urates,  dryness  of  the  skin  or  sweating;  and  by 
nervous  disturbances  varying  from  delirium  to  coma.  There  is  a 
leukocytosis  unless  the  intoxication  is  slight  or  overwhelming,  but  no 
organism  in  the  blood.  In  the  young  and  robust  the  symptoms  are 
apt  to  be  active  {sthenic  fever) ;  in  the  debilitated,  in  the  old,  and 
even  in  the  young,  when  protracted,  they  are  apt  to  be  of  a  low  type 
and  associated  with  marked  exhaustion  {typhoid  state,  asthenic  or 
adynamic  fever).  The  local  symptoms  are  those  of  inflammation, 
and,  if  there  be  a  wound,  usually  a  copious  and  foul  smelling  dis- 
charge. 


1 68  MANUAL    or    SURGERY 

Septicemia  {pyogenic  bacteremia)  is  septic  intoxication  plus  the 
presence  of  living  pyogenic  bacteria  in  the  blood  stream  and  differs 
from  pyemia  only  by  the  absence  of  secondary  abscesses.  The  organ- 
isms gain  entrance  to  the  blood  by  the  lymph  vessels  as  the  result  of 
pressure  in  an  abscess  (secondary  septicemia),  or  possibly  in  some  cases 
pass  directly  into  the  open  capillaries  without  the  existence  of  sup- 
puration {primary  septicemia).  Cryptogenic  septicemia  presents  no 
wound  or  focus  of  suppuration;  a  forgotten  needle  puncture,  or  an 
abrasion  on  the  skin  or  one  of  the  mucous  membranes  may  be  respon- 
sible for  these  cases,  which  become  fewer  as  the  surgeon  increases  in 
experience  and  investigates  with  more  care.  Bacteria  in  the  circulat- 
ing blood  are  devoured  by  the  leukocytes,  or  dissolved  by  the  blood 
serum,  thus  terminating  the  process;  or.  if  sufficiently  numerous  or 
virulent,  and  especially  if  the  individual  has  not  sufficient  resistance 
to  manufacture  antibacterial  serums  or  opsonins,  they  multiply, 
continue  to  elaborate  toxins,  and  are  distributed  to  various  parts  of 
the  body,  where  they  may  cause  secondary  or  metastatic  abscesses 
(pyemia) ;  some  are  eliminated  by  the  excretory  organs,  some  destroy- 
ed by  the  tissue  cells.  There  is  no  specific  micro-organism  of  sep- 
ticemia, any  one  of  the  pyogenic  bacteria  seemingly  being  capable  of 
producing  the  condition,  although  the  streptococcus  bears  the  worst 
reputation  in  this  respect. 

The  symptoms  may  be  noticed  a  few  hours  after  a  wound,  or  not 
for  several  days.  There  is  usually  a  chill,  with  a  rapid  rise  in  tem- 
perature to  104°  or  105°  F. ;  the  fever  persists,  being  less  in  the  morn- 
ing and  greater  in  the  evening;  in  many  cases  there  are  violent  chills 
at  regular  periods,  followed  by  high  temperature  and  drenching  sweats. 
The  pulse  increases  in  rapidity  and  decreases  in  tension.  In  severe 
cases  the  pulse  rate  reaches  150  or  more,  finally  becoming  so  rapid  and 
weak  that  it  cannot  be  counted.  There  is  often  marked  depression 
of  the  nervous  system,  the  patient  being  stupid  and  quiet  (typhoid 
state) ;  or  dehrium,  restlessness,  picking  at  the  bed  clothes  and  twitch- 
ing of  the  tendons;  in  either'case  coma  precedes  death.  Although 
the  respirations  are  quickened,  signs  of  imperfect  oxygenation  of  the 
blood  are  often  seen  in  the  face,  which  may  be  cyanotic.  The  tongue 
is  dry,  coated,  red  at  the  edges,  pointed  at  the  tip,  and  sordes  are 
present  upon  its  dorsum  and  upon  the  lips.  There  are  loss  of  appe- 
tite, occasionally  vomiting,  often  diarrhea.  Petechiae  may  appear 
in  the  skin  and  mucous  membranes,  and,  owing  to  the  disintegration 
of  red  blood  cells,  hematogenous  jaundice  may  develop.  The  skin 
may  present  eruptions  also  in  the  form  of  vesicles  or  pustules,  or 
simulate  urticaria,  measles,  or  scarlet  fever.     The  urine  is  scanty, 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 69 

high  colored,  and  contains  albumin,  toxins,  and  frequently  bacteria; 
the  spleen  and  often  the  liver  are  enlarged,  and  there  may  be  leuko- 
cytosis. Bacteria  may  be  discovered  in  the  blood  by  cultural 
methods. 

The  local  manifestations  vary  from  slight  inflammation  to  the 
graver  forms  of  cellulitis  and  are  not  always  characteristic,  although  in 
many  cases  the  wound  discharges  a  thin  pus,  while  the  activity  of 
the  lymphatic  vessels  is  shown  by  red  lines  of  lymphangitis  running 
to  the  nearest  lymph  glands,  which  are  swollen  and  tender,  or  even 
suppurating.  The  veins  about  a  suppurating  wound  may  become 
inflamed,  and  blocked  with  coagulated  blood  (thrombophlebitis). 
Bacteria  may  invade  and  soften  this  thrombus,  portions  of  which 
may  be  washed  into  the  blood  stream  as  emboli. 

Pyemia  is  septicemia  plus  secondary  or  metastatic  abscesses,  due 
to  the  bacteria  lodging  in  various  parts  of  the  body,  or  to  septic 
emboli  resulting  from  a  thrombophlebitis ;  these  abscesses  may  be  found 
in  any  part  of  the  body,  but  are  most  frequent  in  the  bones,  where 
bacteria  are  readily  deposited  from  the  capillaries  owing  to  the  slowly 
moving  blood  current,  and  in  those  organs  which  also  have  terminal 
arteries,  such  as  the  brain,  spleen,  kidney,  and  lung.  Emboli  arising 
in  the  area  drained  by  the  portal  vein  lodge  in  the  liver  (see  "embo- 
lism")- Compared  with  preantiseptic  days,  pyemia  is  comparative- 
ly rare  at  the  present  time,  but  is  especially  prone  to  follow  acute 
osteomyelitis,  thrombophlebitis  of  the  facial  veins  in  infections  in  this 
neighborhood,  thrombophlebitis  of  the  lateral  sinus  the  result  of 
middle-ear  disease,  and  pyelophlebitis  the  result  of  infective  lesions 
in  the  area  drained  by  the  portal  vein,  notably  appendicitis,  and 
inflammation  about  the  rectum. 

The  symptoms  are  those  of  septicemia,  plus  the  secondary  ab- 
scesses, which  usually  appear  during  the  second  week,  i.e.,  at  the 
time  a  thrombus  disintegrates  into  emboli.  The  metastatic  abscesses 
are  generally  announced  by  an  additional  chill,  but  may  develop 
insidiously,  sometimes  without  even  pain  or  tenderness,  and  they 
are  commonly  small  and  multiple.  Pyemia  may  run  its  course  in  a 
few  days  (acute  pyemia),  or  last  a  number  of  months  {chronic  pyemia). 
It  is  usually  fatal,  although  recovery  has  occurred  despite  the  pres- 
ence of  secondary  abscesses  in  the  internal  organs.  In  pyemia  there 
is  said  to  be  a  characteristic  sweet  odor  not  unlike  that  of  hay. 

Surgical  scarlatina  is  the  name  given  to  the  scarlet  rash,  probably 
the  result  of  vaso-motor  disturbance,  seen  in  cases  of  sepsis.  True 
scarlatina  may,  however,  occur  after  operations  and  accidental 
wounds,  especially  in  children.     Since  the  period  of  incubation  is 


lyo  MANUAL    OF    SURGERY 

shorter  than  in  the  non-surgical  form,  it  may  be  that  the  micro- 
organism of  scarlet  fever  enters  through  the  wound.  Scarlet  rashes 
may  occur  likewise  from  the  absorption  of  ether,  bichlorid  of  mer- 
cury, carbolic  acid,  and  iodoform. 

The  diagnosis  of  sepsis  is  made  by  finding  the  causative  lesion 
and  excluding  other  febrile  maladies.  The  causative  lesion  is  some- 
times difficult  to  locate,  particularly  in  the  so-called  cryptogenic  or 
spontaneous  form,  in  which  it  may  be  necessary  to  review  the  entire 
body  before  finding  the  source  of  infection.  Regions  especially 
liable  to  be  overlooked  are  the  ear,  nose,  accessory  sinuses,  teeth, 
tonsils,  throat,  urethra,  prostate,  rectum,  in  women  the  pelvic  organs 
and  in  children  the  bones,  particularly  the  tibia.  An  insignificant 
wound  that  has  healed  may  be  the  starting  point  of  even  the  gravest 
forms  of  sepsis,  and,  conversely,  a  wound,  even  if  suppurating,  may 
be  complicated  by  other  forms  of  fever.  Here  it  should  be  noted 
that  tonsillitis  may  be  the  cause  and  pneumonia,  endocarditis,  etc., 
the  result  of  sepsis.  The  exclusion  of  aseptic  fever  is  made  by  the 
healthy  appearance  of  the  wound  and  the  brief  duration  of  the 
fever,  of  autointoxication  by  stimulating  the  excretory  organs. 
When  there  is  marked  depression  of  the  nervous  system  and  general 
exhaustion,  typhoid  fever  (Widal  reaction,  leukopenia)  and  mili- 
ary tuberculosis  may  be  simulated,  while  the  occurrence  of  chills  is 
often  wrongly  interpreted  as  malaria;  in  the  last  a  blood  examination 
will  reveal  the  presence  of  malarial  parasites.  The  occurrence  of 
skin  rashes,  particularly  in  children,  will  bring  up  the  question  of  the 
acute  exanthemata,  especially  measles  and  scarlet  fever.  The  form 
of  sepsis  is  toxemia  (saprcmia  or  septic  intoxication)  if,  in  the  pres- 
ence of  an  inflamed  or  suppurating  wound,  the  symptoms  promptly 
subside  after  thorough  drainage  and  disinfection.  If  the  wound  does 
not  show  evidences  of  irritation,  the  constitutional  disturbance  may 
be  due  to  septicemia,  but  is  more  probably  the  result  of  some  medical 
comphcation.  The  continuation  of  fever  after  the  opening  of  an 
abscess  or  wound,  excluding  medical  complications,  usually  means 
inefiicient  drainage,  that  is,  a  continuation  of  the  septic  intoxication, 
or,  if  the  wound  is  perfectly  drained,  septicemia.  In  the  latter  in- 
stance, the  absorption  of  bacteria  may  be  evidenced  by  red  and  tender 
lymph  vessels  coursing  along  the  surface  and  ending  in  inflamed 
lymph  glands;  the  constitutional  symptoms  are  more  severe  than  in 
septic  intoxication,  and  chills  are  more  hkely  to  occur.  A  positive 
diagnosis  can  be  made  only  by  recovery  of  the  organisms  from  the 
blood  stream,  or  from  the  excretions,  particularly  the  urine.  Leuko- 
cytosis and  iodophilia  occur  in  all  forms  of  sepsis.     The  diagnosis 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  171 

of  ])vemia  is  made  by  the  metastatic  abscesses,  which,  when 
superficially  situated,  are  easily  detected;  but  when  deeply  seated 
in  the  viscera,  they  are  apt  to  be  small  and  numerous,  and  often 
their  presence  can  only  be  suspected. 

The  treatment  of  sepsis  is  first  prophylaxis.  All  wounds  acci- 
dentally received  should  be  disinfected,  antiseptic  or  aseptic  pre- 
cautions taken  during  operations  and  the  delivery  of  pregnant 
women.  After  labor  the  placenta  should  be  inspected  to  make  sure 
that  none  of  it  has  been  left  behind;  after  miscarriage  curettage  of 
the  uterus  is  often  done  with  the  same  end  in  view.  It  is  important 
before  operations  also  to  increase  the  resistance  of  the  patient  b\- 
suitable  treatment. 

The  local  treatment  is  that  of  the  causative  lesion,  viz.,  inflamma- 
tion, suppuration,  gangrene,  etc.  Uncomplicated  sapremia  or 
septic  intoxication  rapidly  subsides  if  the  local  cause  be  found  and 
removed.  If  the  symptoms  continue,  all  the  putref}-ing  material  has 
not  been  removed,  drainage  is  not  efficient,  or  bacteria  are  elaborat- 
ing toxins  in  the  blood  stream  fsepticemiaj.  In  the  last  the  outlook 
is  always  grave,  although,  as  has  already  been  indicated,  destruction 
of  bacteria  and  recovery  may  follow.  In  pyemia  secondary  abscesses 
should  be  incised  and  drained,  but  unfortunately,  in  the  \dscera, 
this  is  often  impracticable  owing  to  their  multiplicity.  An  accessi- 
ble vein,  the  subject  of  thrombophlebitis,  should  be  excised, or  (e.g.. 
lateral  sinus)  opened,  the  clot  removed,  and  the  cavity  packed  with 
gauze;  in  order  to  prevent  the  further  dissemination  of  septic 
emboU.  the  vein  may  be  tied  between  the  thrombus  and  the  heart; 
in  the  extremities  amputation  may  be  required. 

The  general  treatment  is  (i)  specific.  (2)  eliminative.  (3)  symp- 
tomatic, (i)  Specific  treatment  aims  to  destroy  bacteria  in  the  blood 
stream  or  to  neutralize  their  toxins.  Unfortunately .  pyogenic  bacteria 
in  the  blood  stream  are  inaccessible.  The  injection  of  antiseptics  into 
the  circulation,  in  sufficient  strength  to  be  of  value,  is  dangerous. 
Antistreptococcic  serum,  which  at  first  seemed  to  give  much  promise, 
has  been  found  to  be  ineffectual;  it  may,  however,  be  employed 
in  10  c.c.  doses  repeated  every  three  or  four  hours,  particularly  if 
bacteriological  examinations  prove  the  infection  to  be  due  to  strep- 
tococci. Like  diphtheria  antitoxin,  which,  too,  has  been  used  in  septic 
conditions  without  success,  it  may  produce  erythematous  or  urtica- 
rial eruptions  and  pains  in  the  joints,  and  several  cases  have  been 
reported  in  which  sudden  death  followed  the  injection  of  the  serum. 
Vaccine  treatment  is  contraindicated.  Quinin,  iron,  and  large  doses 
of  alcohol  fwhisk}'  or  brandy)  are  regarded  by  many  as  almost  specific 


172  MANUAL    OF    SURGER\ 

in  septic  processes.  (2)  The  most  efficient  means  of  combating  sepsis 
is  by  elimination  of  the  micro-organisms  and  their  products.  Purga- 
tion, especially  by  calomel  and  salines,  lowers  the  blood  pressure, 
drains  off  toxins  through  the  bowel,  and  clears  the  intestinal  tract  of 
material  w^hich  may  be  absorbed  and  aggravate  the  symptoms.  If 
nature  has  anticipated  the  physician  by  the  production  of  a  diarrhea, 
such  should  not  be  checked  unless  excessive.  Diuretics,  such  as 
calomel,  cafifein,  squill,  sweet  spirits  of  niter,  acetate  of  potassium, 
and  large  quantities  of  water  by  mouth  or  rectum,  are  of  great  value 
in  removing  toxins  from  the  blood,  and  in  lowering  temperature. 
When  both  the  stomach  and  rectum  are  irritable,  the  same  principle 
may  be  utilized  by  injecting  salt  solution  into  the  subcutaneous  tis- 
sues, or,  exceptionally,  directly  into  a  vein.  Diaphoretics  are  not 
often  used,  as  in  septic  conditions  profuse  sweats  are  generally  pres- 
ent. Venesection  is  occasionally  employed  to  lessen  the  amount  of 
toxin  in  the  circulating  blood,  especially  when  followed  by  the  in- 
travenous injection  of  salt  solution,  or  tranrfusion  of  whole  blood. 
It  should  never  be  used  in  infancy,  old  age,  or  in  the  debihtated. 
(3)  Symptomatic  treatment  depends  upon  the  indications.  Rest  in 
bed,  predigested  liquid  food,  and  proper  nursing  are  always  re- 
quired in  severe  cases  of  sepsis.  The  best  anodyne,  if  the  condi- 
tion is  to  last  but  a  short  time,  is  opium  or  one  of  its  derivatives. 
In  most  surgical  inflammations  pain  severe  enough  to  prevent 
sleep  calls  for  incision  and  drainage  of  the  affected  part.  Nervous- 
ness is  best  met  by  the  bromids,  sleeplessness  not  caused  by 
pain,  by  sulphonethylmethane  or  sulphonmethane.  The  coal-tar 
products  and  chloral,  because  of  their  depressing  effects,  are  usually 
to  be  avoided.  The  best  antipyretic  is  an  ice  cap  on  the  head,  and 
general  sponging  with  ice  water,  or  equal  parts  of  alcohol  and  water; 
drugs  should  rarely  be  employed.  Persistent  fever  usually  means 
that  further  search  for  the  source  of  infection,  with  proper  incisions, 
disinfection,  and  drainage,  should  be  carried  out.  In  many  cases 
stimulants,  such  as  alcohol,  strychnin,  ammonium  carbonate,  and 
digitalis  will  be  needed. 

DELIRIUM 

Mental  aberration  after  an  operation  or  injury  may  be  due  to 
many  causes.  The  delirium  of  sepsis  should  be  excluded,  and  careful 
inquiry  made  into  the  previous  mental  condition  of  the  patient,  and 
into  previous  habits,  especially  regarding  the  use  of  alcohol,  opium, 
and  cocain;  delirium  may  follow  ether  and  chloroform,  and  may  be 
due  to  iodoform  or  carbolic  acid  absorption.     Delirium  is  due  to  an 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 73 

intoxication  in  a  person  who  has  some  bodily  illness,  and  should  not  be 
confused  with  insanity,  which  is  a  disease  of  the  mind,  often  in  an 
otherwise  healthy  body. 

Delirium  tremens  (mania  a  potu)  is  of  frequent  occurrence  in 
chronic  alcoholics  alter  accidents  or  operations  which  require  con- 
finement to  bed,  especially  when  the  individual's  customary  dose  of 
alcohol  is  not  given.  At  first  there  are  restlessness,  insomnia  and 
nightmare.  In  the  course  of  two  or  three  days  the  patient  becomes 
dehrious;  there  are  incessant  incoherent  talking,  constant  motion,  a 
characteristic  termor  of  the  hands  and  of  the  tongue  when  protruded, 
and  hallucinations  of  sight  and  often  of  hearing;  the  patient  sees 
grotesque  individuals  making  grimaces,  or  more  commonly  fights 
snakes,  rats,  or  insects,  w^hich  he  imagines  are  crawling  over  and 
about  him.  The  pulse  increases  in  rapidity,  and  the  temperature 
rises,  rarely  above  103°  F.,  except  in  fatal  cases,  in  which  all  the 
symptoms  increase  in  intensity,  death  occurring  from  exhaustion. 
Recovery  is  the  rule  unless  the  patient  is  otherwise  in  bad  health,  or 
develops  pneumonia,  which  is  a  frequent  complication. 

The  prophylactic  treatment  in  alcoholic  subjects  who  are  to 
undergo  operation,  or  who  have  sustained  an  injury,  consists  in  the 
administration  of  their  customary  tipple,  tonics,  and  nourishing 
food;  if  alcohol  has  been  withheld,  it,  with  bromids,  should  be  given 
at  the  first  appearance  of  tremor,  restlessness,  or  insomnia,  and  the 
patient  carefully  watched,  because  at  the  outbreak  of  delirium  he 
may  tear  off  his  dressings,  or  get  out  of  bed  and  jump  through  a  win- 
dow. In  some  cases  alcohol  seems  to  make  the  condition  worse,  or 
at  least  has  no  effect  in  checking  it.  When  the  attack  has  once 
developed,  the  indications  are  to  quiet  the  nervous  symptoms,  to 
sustain  the  strength,  and  to  maintain  a  constant  watch.  The  nerv- 
ous sedatives  most  frequently  employed  are  the  bromids,  sulphon- 
ethylmethane,  and  sulphonmethane;  chloral  is  too  depressing  to  the 
heart,  and  morphin,  because  of  its  effects  upon  the  secretions,  should 
be  used  only  in  exceptional  cases  or  in  extreme  mania.  Paralde- 
hyde and  hyoscin  are  highly  recommended  by  some  authorities. 
The  strength  is  maintained  by  nourishing  liquid  food,  strychnin, 
and  digitalis,  w^hile  capsicum  is  usually  given  for  its  effect  upon  the 
stomach.  Although  strapping  the  patient  in  bed  aggravates  the 
nervous  symptoms,  it  is  usually  necessary.  Careful  attention,  of 
course,  should  be  given  to  the  bowels  and  kidneys. 

Traumatic  delirium,  or  delirium  nervosum,  is  an  afebrile  dehrium 
occasionally  encountered  after  injuries  or  operations,  particularly  in 
children,  the  senile,  and  the  hysterical.     ^Many  individuals  become 


174  MANUAL    or    SURGERY 

flighty  from  pain  alone.  Delirium  nervosum  appears  several  days 
after  an  opeiation  or  injury  and  may  last  a  week,  very  rarely  ter- 
minating in  death.  It  is  closely  allied  to  the  ''delirium  of  collapse,'" 
which  is  seen  in  some  cases  of  shock,  or  after  the  sudden  fall  of  a  high 
temperature,  and  which  may  last  a  few  hours  or  a  few  days.  The 
treatment  of  delirium  nervosum  is  nervous  sedatives,  attention  to  the 
general  health,  and  the  removal  of  any  local  irritation  which  may 
be  present. 

Genuine  insanity  occasionally  develops  after  an  operation  or 
injury;  it  is  usually  of  the  confusional  type,  but  may  be  of  any 
variety.  The  prognosis  is  good  unless  there  are  systematized 
delusions,  a  strong  ancestral  history  of  insanity,  or  unless  there  has 
been  previous  trouble  with  the  intellect. 

ERYSIPELAS 

Erysipelas  is  an  acute  contagious  and  infectious  inflammation 
of  the  skin,  and  occasionally  of  the  mucous  membranes. 

The  cause  is  the  streptococcus  erysipelatis  (identical  with  the 
streptococcus  pyogenes),  which  lodges  in  an  abrasion  or  wound,  and. 
passing  into  the  capillary  lymphatics  of  the  skin,  gives  rise  to  inflam- 
mation of  these  vessels  and,  by  contiguity,  of  the  remaining  dermal 
structures.  Chronic  alcoholism,  kidney  affections,  and  other  causes 
of  general  debility,  favor  the  development  of  the  malady,  and  in 
certain  indi\-iduals  there  is  a  natural  predisposition,  the  disease 
breaking  out  repeatedly  on  the  slightest  provocation.  It  is  most 
prevalent  in  the  spring,  and  is  especially  prone  to  occur  in  epidemics 
in  overcrowded  hospitals  with  defective  sanitation.  Idiopathic  ery- 
sipelas is  that  form  in  which  no  port  of  entry  can  be  found.  Infec- 
tion through  sound  skin  or  mucous  membrane  is  possible,  but  in  the 
vast  majority  of  the  idiopathic  cases  it  is  probable  that  the  abrasion 
is  so  slight  or  so  situated,  e.g..  just  within  the  nostrils,  that  it  escapes 
detection. 

The  symptoms  appear  within  a  few  hours  or  not  for  several  days 
after  the  microbes  have  entered  a  wound.  They  may  be  inaugu- 
rated by  a  chill,  with  headache  and  malaise,  the  rash  appearing 
a  number  of  hours  later,  but  in  many  cases  the  local  changes  first 
attract  attention.  The  wound  will  have  a  dry,  dirty-yello\\'ish 
appearance,  and  be  surrounded  by  a  bright  red,  shiny  swelhng  which 
spreads  irregularly,  resembhng  a  growing  map;  the  redness  dis- 
appears on  pressure,  and  there  is  a  sensation  of  burning,  tension,  or 
stiffness,  but  no  acute  pain,  unless  dense  structures  like  the  scalp 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 75 

are  invaded;  there  is  edema,  which,  in  loose  structures  like  the 
scrotum  and  e\'elids.  becomes  very  great.  ()\vin<);  to  the  intensity  of 
the  dermatitis,  vesicles  and  bulla;  frequently  develop  and  often 
contain  a  turbid  lluid.  Suppuration,  however,  is  not  common 
unless  the  organism  gains  access  to  the  subcutaneous  tissues,  when 
the  condition  is  called  celhdo-culaneoiis  or  phlegmonous  erysipelas 
(see  ''Celluhtis").  The  skin  is  hot  and  tense,  the  margins  of  the 
swelling  abrupt  and  sharply  defined,  and  the  adjacent  lymph  glands 
swollen  and  tender.  The  fever  is  of  the  continuous  variety  and, 
especially  in  facial  erysipelas,  is  apt  to  subside  by  crisis.  In  those 
whose  health  has  been  depressed  by  general  illness,  in  alcoholics, 
and  in  erysipelas  about  the  head  and  face,  great  prostration  with 
delirium  is  Hkely  to  develop.  As  the  rash  spreads  it  fades  in  those 
areas  which  were  first  attacked,  leaving  a  brownish  discoloration  and 
a  branny  desquamation.  Erysipelas  of  the  fauces  causes  great  swell- 
ing, which  may  spread  to  the  glottis  and  produce  severe  dyspnea. 
Occasionally  erysipelas  will  spread  from  its  point  of  origin,  succes- 
sively involving  contiguous  areas  {ambulant,  erratic,  migratory,  or 
wandering  erysipelas) .  Again  it  may  jump  from  one  region  of  the 
body  to  some  distant  region  [metastatic  erysipelas).  Erysipelas 
which  begins  in  the  cicatrizing  umbilicus  of  the  new-born  {erysipelas 
neonatorum)  is  very  fatal.  Every  now  and  then  a  mahgnant  growth, 
chronic  ulcer,  or  ancient  skin  disease  will  disappear  after  it  has  been 
invaded  by  erysipelas  {erysipelas  salutaire).  The  disease  lasts  from 
a  few  days  to  several  weeks.  The  mortality  is  from  5  to  7  per  cent. 
Death  is  usually  the  result  of  toxemia,  although  it  may  arise  from  a 
complication,  such  as  meningitis,  pneumonia,  endocarditis,  nephritis, 
or  pyemia. 

The  diagnosis  of  erysipelas  is  rarely  difhcult.  It  is  most  fre- 
quently confused  with  cellulitis,  in  which  the  redness  is  more  dusky, 
the  margins  not  so  abrupt  and  irregular,  and  the  pain  deeper  and 
more  throbbing. 

Treatment. — The  prophylactic  treatment  consists  in  the  isolation 
of  cases  of  erysipelas  which  develop  in  a  surgical  ward.  During  an 
epidemic  none  but  imperative  operations  should  be  performed. 
Those  who  nurse  or  dress  cases  of  erysipelas  should  not  come  in 
contact  with  surgical  or  obstetrical  patients. 

The  local  treatment  consists  in  the  disinfection  of  any  existing 
wounds  and  the  application  of  antiseptic  fomentations.  The  various 
solutions  and  ointments  which  have  been  recommended  seem  to  have 
little  effect  upon  the  progress  of  the  disease;  the  most  popular  of 
these  is  ichthyol,  25  per  cent.     Cataplasm  of  kaolin  makes  a  com- 


176  MANUAL    OF    SURGERY 

fortable  application.  Evaporating  lotions  and  cold  compresses  ease 
the  pain,  but  should  be  used  cautiously  in  asthenic  cases.  Irritat- 
ing medicaments,  e.g..  iodin.  turpentine,  etc.,  should  not  be  applied 
to  the  inflamed  area.  In  order  to  prevent  the  spread  of  erysipelas, 
the  affected  part  has  been  surrounded  by  a  circle  painted  with  a 
strong  solution  of  silver  nitrate  or  tincture  of  iodin,  by  injections  of 
a  3  per  cent.  carboHc  acid  solution  or  other  antiseptic,  by  incisions, 
and  by  a  circle  burned  with  the  cautery.  All  these  methods  aim  to 
produce  a  barrier  of  leukocytes,  in  other  words,  an  inflammation  is 
produced  to  stop  an  inflammation.  The  results  of  this  homeopathic 
form  of  treatment  do  not  justify  its  continuance.  The  apphcation 
of  pressure  by  collodion  or  strips  of  adhesive  plaster  is  occasionally 
effective  in  limiting  the  disease.  When  suppuration  is  threatened, 
or  in  the  cellulo-cutaneous  variety,  incisions  are  indicated.  Erysipe- 
las of  the  fauces  should  be  treated  by  sprays  or  gargles  of  mildly 
antiseptic  solutions,  and  by  the  application  of  ice  externally;  the 
patient  should  be  carefully  watched  for  e\'idences  of  edema  of  the 
glottis,  which  may  require  tracheotomy. 

The  constitutional  treatment  is  that  of  sepsis.  Tinture  of  chlorid  of 
iron,  10  to  20  drops  three  or  four  times  a  day,  is  regarded  by  some  as  a 
specific,  especially  when  combined  with  quinin.  Pilocarpin  given 
internally  has  been  recommended  for  its  action  on  the  skin.  Anti- 
streptococcic serum  should  theoretically  be  of  great  value. 
Mormorek.  the  originator  of  antistreptococcic  serum,  has  treated 
423  cases  of  erysipelas  with  his  serum.  \\'ith  a  mortality  of  3.87  per 
cent.  The  serum  has  been  injected  around  the  area  of  inflammation, 
as  well  as  in  in  dift'erent  portions  of  the  body. 

Erysipeloid  is  an  infective  dermatitis  caused  by  inoculation  of  a 
wound  or  abrasion  with  putrid  animal  matter,  hence  is  most  frequent 
on  the  hands  of  cooks,  butchers,  and  lish  dealers.  The  swelHngis  red, 
painful,  and  sharply  defined,  and  tends  to  spread  over  the  rest  of  the 
hand.  Suppuration.  l}Tnphangitis,  and  the  formation  of  vesicles  do 
not  occur,  and  general  s\-mptoms  are  sUght  or  absent.  The  treatment 
is  disinfection  of  the  wound  and  mildly  antiseptic  dressings. 

CELLULITIS 

Cellulitis,  or  inflammation  of  the  areolar  connective  tissue,  may 
be  found  in  any  region  in  which  there  is  cellular  tissue  (see  "CelluHtis 
of  the  Xeck,"  "Peh-ic  Cellulitis."  ''Periproctitis,"  etc.),  but  here  we 
refer  only  to  the  subcutaneous  variety.  It  may  be  acute  or  chronic. 
Chronic  cellulitis  is  alwavs  circumscribed;  it  may  follow  the  acute 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 77 

form,  but  is  more  often  seen  as  a  thickening  of  the  tissues  about  some 
long-continued  source  of  irritation,  e.g.,  a  chronic  ulcer,  and  subsides 
when  the  cause  is  removed.  Acute  cellulitis  may  be  circumscribed 
or  diffuse.  Acute  circumscribed  cellulitis  occurs  about  inflamed 
wounds,  spreading  ulcers,  and  tight  stitches.  The  inflamed  tissues 
occasionally  suppurate  or  slough,  but  the  process  remains  localized 
and  promptly  subsides  with  appropriate  treatment. 

Acute  diffuse  cellulitis  idifuse  phlegmon,  purulent  infiltration)  is  a 
widespread  suppurative  inflammation  of  the  subcutaneous  cellular 
tissue.  It  is  usually  caused  by  the  infection  of  wounds  with  the 
streptococcus  pyogenes,  and  is  indistinguishable  clinically  from 
cellulo-cutaneous  or  phlegmonous  erysipelas.  The  less  severe  varieties 
are  due  to  staphylococci.  In  either  case  the  dose  and  \drulency  of 
the  organism  and  the  general  condition  of  the  patient  determine  the 
extent  and  severity  of  the  process. 

The  S3ai]ptoms  may  appear  within  a  few  hours  or  not  for  two  or 
three  days  after  the  infection  of  a  wound.  The  inflammation  spreads 
rapidly,  and  may  extend  over  a  whole  limb.  There  are  intense  pain, 
great  swelling  and  edema,  dusky  redness,  and  elevation  of  the  local 
temperature.  The  lymphatic  vessels  running  from  the  infected  area 
may  be  tense,  red,  and  tender,  and  the  glands  into  which  they  empty, 
painful  and  swollen.  The  suppuration  may  spread  not  only  beneath 
the  skin,  but  between  muscles,  beneath  fascia,  and  even  to  the  bone. 
The  subcutaneous  tissue  sloughs,  and  gangrene  of  the  skin  may  occur 
from  the  cutting  off  of  its  blood  supply.  When  the  tendency  to 
gangrene  is  excessive  the  condition  is  called  gangrenous  cellulitis; 
when  there  is  gas  in  the  tissues,  gas  gangrene  (q.v.).  The  constitu- 
tional symptoms  are  those  of  septic  intoxication  or  septicemia; 
occasionally  pyemia  develops. 

Treatment. — Celluhtis  may  be  prevented  by  the  disinfection  of 
all  abrasions  and  wounds,  and  their  exclusion  from  septic  contamina- 
tion by  sterile  or  antiseptic  dressings.  It  may  be  aborted  by  open- 
ing, disinfecting,  and  draining  inflamed  wounds.  When  it  has  once 
gained  headway,  free  incisions  should  be  made,  whether  there  be 
suppuration  or  not,  in  order  to  relieve  tension  and  drain  the  tissues 
of  the  inflammatory  exudate  and  bacterial  products.  In  the  milder 
varieties  early  incisions  may  prevent  suppuration,  in  the  severer 
forms  they  will  at  least  limit  it;  these  incisions  are  disinfected  with 
peroxid  of  hydrogen,  followed  by  hot  bichlorid  of  mercury  solution, 
I  to  1000,  and  are  hghtly  packed  with  gauze,  the  whole  part  being 
covered  wdth  a  bichlorid  dressing  and  put  at  rest.  The  limb  should  be 
elevated,  frequently  dressed  and  irrigated,  and  further  incisions  made  if 


178  MANUAL    OF    SURGERY 

spreading  continues.  Inflamed  lymph  vessels  and  glands  ma}'  be  cov- 
ered with  ichthyol  ointment;  if  the  glands  suppurate,  they  should 
be  incised  or  excised.  If  there  is  a  tendency  to  sloughing,  warm 
antiseptic  fomentations  should  be  apphed,  and  the  sloughing  tissue 
removed  as  quickly  as  it  separates.  Constant  irrigation  with  a  mild 
antiseptic  solution,  which  descends,  by  means  of  a  gauze  wick, 
from  a  reservoir  suspended  over  the  part,  and  then  is  caught  in  a 
suitably  arranged  sheet  of  rubber  to  be  drained  into  a  receptacle  on 
the  floor,  is  sometimes  of  service,  as  is  also  immersion  of  the  part 
in  a  continuous  warm  bath.  The  Carrel-Dakin  method  or  one  of  its 
substitutes  may  prove  valuable  in  this  condition.  The  constitu- 
tional treatment  is  that  of  sepsis  (q.v.). 

TETANUS 

Tetanus  (lockjaw)  is  an  infectious  disease  characterized  by  tonic 
spasms  of  the  muscles,  especially  those  of  mastication. 

The  cause  is  the  bacillus  of  tetanus,  which  is  a  rod-like  organism, 
usually  presenting  a  distinct  enlargement  at  one  end,  owing  to  the 
presence  of  a  spore  (drumstick  bacillus).  It  is  an  anaerobe,  a  fact 
which  explains  the  frequency  of  tetanus  after  punctured  wounds, 
which  quickly  heal  at  the  surface  and  form  an  ideal  chamber  for  the 
growth  of  the  organism.  It  is  most  frequently  found  in  cultivated 
earth  and  in  the  feces  of  animals,  hence  the  susceptibihty  of  hostlers 
and  "sons  of  the  soil."  The  predisposition  which  is  supposed  to  be 
possessed  by  the  negro  is  probably  due  to  this  fact.  As  heat  favors 
the  development  of  the  organism,  the  disease  is  particularly  preva- 
lent in  the  tropics.  Aside  from  punctured  wounds,  the  bacillus 
finds  a  most  favorable  field  for  development  in  septic  wounds, 
owing  to  the  absorption  of  oxygen  by  other  organisms  present 
(symbiosis).  Punctured  wounds  of  the  sole  of  the  foot  are  notorious 
for  the  frequency  with  which  they  are  followed  by  tetanus,  because 
the  vulnerating  body,  often  a  rusty  nail,  has  become  contaminated 
by  lying  in  contact  with  the  earth.  Blank  cartridge  wounds  are 
particularly  dangerous,  no  doubt  because  the  wads  are  often  made  of 
horsehair  felt.  Tetanus  has  followed  also  the  injection  of  gelatin  for 
aneurysm,  the  injection  of  diphtheria  antitoxin,  and  vaccination. 
Gelatin,  it  will  be  recalled,  is  derived  from  the  hoofs,  hides,  etc.,  of 
cattle;  diphtheria  antitoxin  from  the  blood  serum  of  horses;  and 
the  virus  used  for  vaccination,  from  cows.  Occasionally  no  wound 
can  be  found  {idiopathic  tetanus),  although  it  is  possible  in  these  cases 
that  the  bacilli  enter  the  tissues  through  an  ulcer  or  abrasion  in  the 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 79 

alimentary  canal.  The  bacilli  have  little  tendency  to  migrate  from 
the  point  of  inoculation,  being  rarely  found  in  the  blood.  Telano- 
toxin  is  composed  of  two  bodies,  viz.,  letanospasmin,  which  produces 
convulsions,  and  tetanolysin,  which  destroys  red  blood  cells.  The 
toxin  reaches  the  ganglia  of  the  central  nervous  system,  not  by  the 
blood,  but  by  the  motor  nerves,  along  the  axis  cylinders  of  which  it 
slowly  creeps,  thus  explaining  the  long  incubation  and  the  congested 
appearance  of  the  nerves  leading  from  the  wound.  The  sensory  ner- 
ves take  no  part  in  the  process.  That  portion  of  the  toxin  which 
finds  its  way  into  the  general  circulation  is  not  absorbed  directly 
by  the  ganglia,  but  is  distributed  to  the  ends  of  the  motor  nerves 
throughout  the  body,  then  passing  upward  along  the  nerves  to  the 
cord ;  thus  the  period  of  incubation  is  the  same  when  the  toxin  is  in- 
jected into  the  subarachnoid  space. 

The  period  of  incubation  of  acute  tetanus  varies  from  a  few  hours 
to  two  weeks,  usually  being  within  ten  days.  The  first  symptom  is 
stiffness  of  the  lower  jaw,  which  later  becomes  fixed,  the  patient  being 
unable  to  open  the  mouth  {trismus,  or  lockjaw).  The  spasm  extends 
more  or  less  rapidly  to  the  other  voluntary  muscles  of  the  body. 
Spasm  of  the  muscles  of  expression  moulds  the  face  into  a  charac- 
teristic grin  {risus  sardonicus) .  As  the  muscles  of  the  back  are  the 
more  powerful,  generalized  convulsions  usually  cause  the  patient  to 
rest  upon  the  head  and  heels  (opisthotonos),  but  the  whole  body  may 
be  stifif  and  straight  (orthofonos),  bent  to  one  side  (pleurosthotonos) , 
or  curved  forward  {emprostJwtonos).  Spasm  of  the  pharyngeal 
muscles  causes  dysphagia,  of  the  diaphragm  girdle  pain,  of  the  laryn- 
geal muscles  dyspnea,  of  the  sphincter  vesicae  retention  of  urine,  of 
the  sphincter  ani  constipation.  The  mind  is  clear,  and  the  pain  very 
great,  owing  to  the  cramp-like  contracture  of  the  muscles,  which 
never  entirely  relax,  and  which  are  thrown  into  more  acute  contrac- 
tion by  the  slightest  irritation,  such  as  a  draught  of  air,  an  attempt  to 
take  food,  etc.  During  these  convulsions  the  patient  is  cyanotic 
from  spasm  of  the  respiratory  muscles,  the  body  is  covered  with  sweat, 
the  eyes  protude,  and  muscles  may  be  ruptured,  teeth  broken,  or  the 
tongue  bitten  through.  The  temperature  is  usually  normal  at  the 
beginning,  but  generally  rises  before  death,  and  continues  to  rise 
after  death,  often  reaching  io8°  or  iio°  F.  The  end  usually  comes 
within  four  or  five  days,  from  heart  failure  or  asphyxia  during  a 
convulsion,  or  from  exhaustion. 

Chronic  tetanus  has  a  longer  period  of  incubation  than  the  acute 
form,  milder  symptoms,  and  a  much  better  prognosis.  Sometimes 
the  spasms  are  Hmited  to  that  portion  of  the  body  in  which  the  infec- 


l8o  MANUAL    OF    SURGERY 

tion  has  taken  place  {local  tetanus).  In  cephalic  tetanus  {tetanus 
paralyticus,  tetanus  hydro pliohicus).  which  follows  injuries  in  the  area 
supplied  by  the  cranial  nerves,  trismus  and  dysphagia  are  often 
accompanied  by  facial  paralysis,  from  neuritis  of  the  seventh  nerve. 
Chronic  cephalic  tetanus  presents  a  fairly  good  prognosis  (25  per 
cent,  mortality),  but  in  some  cases  it  is  acute  and  associated  with 
generalized  convulsions,  and  is  then  quite  as  grave  as  ordinary 
acute  tetanus. 

A  number  of  cases  of  so-called  late  tetanus  were  observed  during 
the  war.  In  some  instances  the  disease  was  postponed  because 
of  partly  successful  prophylactic  treatment  and  was  of  a  mild  type. 
In  others  the  attack  was  precipitated,  sometimes  months  after  the 
original  injury,  by  operation  on  a  previously  infected  region,  the 
latent  bacilli  being  mobilized  by  the  operative  trauma. 

Tetanus  neonatorum,  or  trismus  nascentium,  is  tetanus  in  the  new- 
born, due  to  infection  through  the  navel. 

The  mortality  of  acute  tetanus  is  from  80  to  90  per  cent.,  of  the 
chronic  variety  from  40  to  50  per  cent.  A  long  period  of  incubation, 
a  normal  temperature,  and  limitation  of  the  spasms  to  the  injured 
part  are  favorable  signs.  If  death  does  not  occur  within  a  week, 
recovery  may  be  expected. 

Diagnosis. — Trismus,  or  closure  of  the  jaws,  arising  from  inflam- 
matory troubles,  etc.  (see  "Closure  of  the  Jaws"),  is  not  accompanied 
by  rigidity  of  the  neck  or  generahzed  convulsions,  and  the  cause, 
e.g.,  tonsillitis,  unerupted  wisdom  tooth,  will  readily  be  found  upon 
examination.  In  strychnin  poisoning  there  is  complete  relaxation 
between  the  spasms,  including  the  jaw  muscles,  so  that  the  mouth 
may  be  widely  opened;  the  convulsions  are  more  abrupt  in  onset, 
and  the  hands  are  tightly  contracted,  an  unusual  sign  in  tetanus; 
and  there  may  be  hyperesthesia  of  the  retinse  with  green  vision.  In 
hysteria  there  may  be  blindness,  laughing  or  crying  spells,  loss  of  con- 
sciousness, and  during  the  spasm  closure  or  quivering  of  theeyehds. 
Occasionally  the  patient  is  rigidly  fixed  in  one  position  and  remains  so 
for  hours  (catalepsy).  Wood  states  that  in  hysteria  the  feet  are 
crossed  and  the  toes  inverted;  in  spasm  of  all  the  muscles  of  the 
leg  the  feet  are  turned  out,  because  the  muscles  of  eversion  are 
stronger.  Tetany  is  characterized  by  tonic  local  spasms,  especially 
of  the  hands  and  feet,  and  trismus  is  rarely  present.  In  hydro- 
phobia the  convulsions  are  hmited  to  the  muscles  of  respiration  and 
deglutition,  are  clonic  and  not  tonic,  and  are  associated  with  mania. 
Bacteriological  examination  of  any  existing  wound  may  be  of  value 
in  doubtful  cases. 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  l8l 

The  Treatment. — The  prophylactic  treatment  consists  in  the  disin- 
fection of  all  accidental  wounds.  Punctured  wounds,  unless  pro- 
duced by  an  evidently  clean  instrument,  should  be  excised  or  incised, 
disinfected,  and  drained.  'J'hey  should  not  be  cauterized,  because 
the  resulting  eschar  excludes  the  air  from  the  deeper  portions,  and 
thus  favors  the  development  of  the  tetanus  bacillus.  Next,  1500 
units  of  antitetanic  serum  should  be  injected  subcutaneously.  As 
the  immunity  from  a  single  dose  of  the  antitoxin  is  supposed  to 
last  about  eight  days,  a  second  injection  may  be  given  at  the  end 
of  a  week,  and  a  third  at  the  end  of  two  weeks.  The  repeated 
injections  are  especially  indicated  when  the  wound  has  been  soiled 
with  earth  or  manure.  Occasionally  tetanus  develops  despite  the 
use  of  the  antitoxin,  but  is  then  usually  of  a  mitigated  form.  Ref- 
erence has  already  been  made  to  the  treatment  of  blank  cartridge 
wounds.  Gelatin  and  various  antitoxins  should  not  be  used 
subcutaneously  until  they  have  been  proved  free  from  tetanus  by 
injection  into  susceptible  animals.  The  virus  used  for  vaccination 
against  small-pox  should  be  that  which  comes  in  hermetically 
sealed   tubes,    and   the   operation   must  be  performed  aseptically. 

When  the  disease  has  once  manifested  itself,  the  wound  should  be 
excised  and  the  part  dressed  with  antiseptic  fomentations.  In 
wounds  too  large  for  excision,  and  even  in  smaller  wounds,  amputa- 
tion may  properly  be  considered.  The  most  useful  antiseptic  in 
wounds  which  are  not  excised  is  Dakins  solution;  strong  tincture  of 
iodin,  I  per  cent,  solution  of  silver  nitrate,  and  bichlorid  of  mercury, 
I  to  500  can  be  used  after  the  dead  tissue  has  been  removed. 
Stretching  the  main  nerve  trunks  supplying  the  affected  part  has 
been  employed  with  occasional  success;  it  may  be  that  this  procedure 
interferes  with  the  transference  of  the  toxin  along  the  nerves.  Far 
better,  at  least  theoretically,  is  the  injection  of  antitoxin  into  these 
nerves.  For  this  purpose  the  patient  should  be  chloroformed;  and  the 
motor  nerves  which  supply  the  region  primarily  infected  exposed  as 
near  the  cord  as  possible  and  each  injected  by  a  fine  hypodermic 
needle  with  from  5  to  10  or  20  cc.  of  antitoxin  (Rogers).  When  in- 
jected subcutaneously,  the  antitoxin  neutrahzes  only  that  portion  of 
the  toxin  which  is  in  the  circulating  blood,  and  not  that  which  is  in 
the  nervous  system,  as  it  is  not  absorbed  by  the  nerves  as  is  the  toxin. 
Antitoxin  has  been  injected  also  around  the  infected  part,  directly 
into  a  vein,  into  the  subarachnoid  space,  and,  after  making  a  small 
trephine  opening  in  the  skull,  directly  into  the  frontal  lobes  of  the 
brain,  or  into  the  lateral  ventricle.  Park  and  Nicoll  advise  inject- 
ing from  3000  to  5000  units  intraspinally,  after  lumbar  puncture, 


1 82  MANUAL  OF  SURGERY 

allowing  to  escape  an  amount  of  fluid  equivalent  to  that  injected. 
At  the  same  time  from  10,000  to  15.000  units  are  injected  into 
a  vein.  The  intraspinal  injections  may  be  repeated  daily.  In 
addition  5000  units  may  be  given  subcutaneously  every  day.  It 
is  probable  that  with  the  onset  of  symptoms  the  tetanus  toxin 
has  already  fatally  embraced  the  cells  of  the  central  nervous 
system,  and  that  antitoxin  administered  in  any  form  is  quite 
impotent  to  repair  the  damage  already  done.  Emulsions  of  fresh 
brain  tissue  have  been  injected  hypodermatically,  on  the  principle 
that  the  toxin  would  unite  with  these  nervous  cells  and  thus  become 
neutralized. 

Even  though  antitoxin  is  employed,  the  patient  should  be  isolated 
in  a  darkened  chamber  and  guarded  from  all  forms  of  irritation. 
Bromids,  chloral,  and  morphin  should  be  regularly  administered, 
and  the  convulsions  controlled  by  chloroform.  Section  of  the 
phrenic  nerves  in  the  neck  and  tracheotomy  have  been  advised 
for  menacing  cramp  of  the  respiratory  muscles,  but  should  be 
unnecessary  if  one  has  an  intratracheal  insulation  apparatus. 
If  trismus  is  marked,  nasal  feeding  may  be  adopted,  by  the 
passage  of  a  rubber  catheter  into  the  pharynx  through  the  nose,  or 
food  may  be  administered  by  rectum.  Other  drugs  which  have 
been  recommended  are  curare,  cannabis  indica.  gelsemium,  physo- 
stigma.  and  iodoform.  Venesection  to  lessen  the  amount  of 
toxin  in  the  circulating  blood,  followed  by  intravenous  infusion  of 
salt  solution,  is  occasionally  employed.  The  subarachnoid  in- 
jection of  magnesium  sulphate,  cocain,  etc.,  as  in  spinal  anesthesia, 
also  has  been  used  and  appears  to  be  of  some  value  in  controlling 
the  convulsions. 

HYDROPHOBIA 

Hydrophobia  (rabies,  lyssa)  is  an  infectious  disease  resulting 
from  the  bites  of  animals,  especially  the  dog,  cat,  and  wolf.  The 
specific  micro-organism  is  probably  identical  with  the  so-called 
Negri  bodies  (vide  infra).  The  virus  is  found  in  the  saliva,  in  the 
central  nervous  system,  and  occasionally  in  the  lachrymal  gland, 
pancreas,  and  mammary  gland.  It  is  not  found  in  the  blood,  and 
further  resembles  the  toxin  of  tetanus  in  that  it  has  a  marked 
affinity  for  the  central  nervous  system,  to  which  it  is  conveyed  by 
the  nerves.  As  in  tetanus,  the  wound  is  often  punctured,  and  may 
heal  before  the  onset  of  symptoms,  and  again  become  painful  as 
the  disease  develops.     Between  10  and  25  per  cent,  of  those  bitten 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 83 

by  rabid  animals  subsequently  dexelop  hy(lroi)hobia.  Cases  have 
been  reported  in  which  the  disease  has  followed  the  mere  licking  of  the 
hand  by  a  rabid  dog.  Bites  through  clothing,  which  may  wipe  the 
virus  from  the  teeth  of  the  animal,  are  less  dangerous  than  those  on 
exposed  parts,  while  bites  in  parts  richly  supi)lied  by  nerves,  such 
as  the  face  and  hands,  arc  the  most  dangerous.  The  virus  is  present 
in  the  saliva  for  several  days,  sometimes  as  long  as  eight,  before  the 
development  of  symptoms,  thus  sustaining  the  popular  belief  that 
hydrophobia  may  follow  the  bite  of  a  dog  which  later  becomes  rabid. 
The  period  of  incubation  in  man  varies  from  a  few  weeks  to  several 
months,  the  average  being  forty  days.  The  disease  is  most  frequent 
during  the  summer  months.  The  gross  changes  usually  found  after 
death  are  those  of  congestion  of  the  brain  and  membranes.  Micro- 
scopically, the  most  important  findings  are  (i)  aggregations  of 
embryonic  cells  in  the  motor  nuclei  of  the  medulla  and  cord  (rabic 
tubercles  of  Babes) ;  (2)  degeneration  of  the  cerebrospinal  and  sympa- 
thetic ganglia,  especially  the  plexiform  ganglia  of  the  pneumogastric 
nerve  and  Gasserian  ganglion,  the  nerve  cells  being  replaced  by  pro- 
hferated  endothelial  cells  derived  from  the  capsule;  and  (3)  Negri 
bodies  (thought  by  Negri  to  be  protozoa  and  the  cause  of  rabies), 
which  are  small  bodies  found  in  the  cells  of  the  central  nervous  sys- 
tem, particularly  in  the  Purkinje  cells  of  the  cerebellum  and  in  the 
large  ganglion  cells  in  the  region  of  Amnion's  horn.  Noguchi  claims 
to  have  cultivated  the  Negri  bodies,  and  reproduced  the  disease 
with  the  cultures.  The  degenerative  lesions  of  the  ganglia  and  the 
Negri  bodies  are  pathognomonic,  so  that  a  positive  diagnosis  may  be 
made  by  the  examination  of  an  animal  after  death.  In  order  that 
these  changes  may  occur,  the  animal  should  not  be  killed,  but  allowed 
to  die  from  the  disease.  The  head  may  then  be  removed  and  sent  to 
a  pathologist  for  diagnosis,  which  may  be  further  confirmed  by  in- 
jecting an  emulsion  of  the  nervous  tissue  into  a  susceptible  animal. 
In  animals  the  presence  of  foreign  bodies,  such  as  stone,  hair,  etc.,  in 
the  stomach,  owing  to  the  depraved  appetite  characteristic  of  the 
disease,  strongly  points  to  rabies. 

In  the  dog  the  symptoms  appear  usually  in  from  three  to  five 
weeks  after  infection.  In  the  racing,  or  maniacal  rabies,  there  is 
first  a  stage  of  depression,  characterized  by  irritability,  restlessness, 
abnormal  appetite  (for  rubbish,  etc.),  dysphagia,  and  nausea.  This 
stage  lasts  for  two  or  three  days,  and  is  the  dangerous  one  for  man, 
because  the  disease  may  not  be  suspected.  This  is  followed  by  a 
stage  of  madness,  or  frenzy,  lasting  three  or  four  days,  in  which  the 
dog  charges  about,  barking  furiouslv  with  a  hoarse  bark,  and  biting 


184  MAXTAL  OF  SURGERY 

anything  with  which  it  comes  in  contact;  this  stage  terminates  in 
paralysis  and  death.  From  the  beginning  there  is  a  large  quantity  of 
ropy  saliva  secreted.  In  the  quiet,  or  melancholy  form,  the  disease 
skips  from  the  first  to  the  third  stage,  death  occurring  w^ithin  two 
or  three  days  from  the  beginning. 

In  man  the  symptoms  of  the  first  stage  are  restlessness,  excita- 
bility, a  vague  terror,  insomnia,  anorexia,  and  occasionally  some 
thickening  of  the  cicatrix,  which  may  be  the  seat  of  a  burning  or 
itching  pain.  These  symptoms  last  about  twenty-four  hours,  and 
are  succeeded  by  the  second  stage,  in  which  there  are  dysphagia 
owing  to  spasm  of  the  pharynx,  and  dyspnea  from  spasm  of  the 
respiratory  muscles.  The  spasms  are  clonic  in  character,  may  be- 
come more  or  less  generalized,  and  are  precipitated  by  the  slightest 
irritation,  especially  by  attempts  to  swallow  hquid,  hence  the  term 
hydrophobia.  As  in  the  dog,  there  is  a  large  quantity  of  ropy  mucus 
and  sahva  secreted.  Owing  to  the  spasm  of  the  respiratory  muscles, 
noises,  which  have  been  likened  to  the  barking  of  a  dog,  may  be 
produced.  During  this  stage  there  are  outbreaks  of  mania  with 
lucid  intervals.  There  is  usually  very  httle  fever,  and  at  the  end  of 
one  to  three  days  death  occurs  from  a  rapidly  ascending  paralysis. 
Xo  authentic  case  of  infection  of  man  by  man  has  been  reported. 
The  disease  invariably  results  in  death. 

The  Treatment. — In  the  prophylactic  treatment  should  be  men- 
tioned the  muzzhng  of  dogs.  A  wound  produced  by  a  supposedly 
mad  dog  should  be  squeezed  and  sucked,  and  disinfected  with  for- 
maldehyd  solution,  5  per  cent.,  which,  according  to  Gumming,  is  a 
specific ;  cauterization  is  not  recommended.  When  on  an  extremity,  a 
hgature  should  be  placed  above  the  bite  until  the  wound  has  been 
disinfected.  Excision  is  preferable,  and  may  be  efiicacious  even  a 
number  of  days  after  the  injury,  as  the  virus  tends  to  remain  localized 
and  merely  creeps  along  the  nerves.  The  animal  should  not  be 
killed,  but  allowed  to  die  of  the  disease,  if  it  be  really  present,  when 
a  positive  diagnosis  may  be  made.  As  soon  as  possible  after  inocu- 
lation the  patient  should  be  given  the  Pasteur  treatment  (antirabies 
vaccination),  which  is  prophylactic  and  not  curative.  It  is  founded 
on  the  principle  of  inducing  active  immunity  by  the  injection  of 
ascending  doses  of  the  virus.  The  most  virulent  virus  obtainable 
is  secured  by  passing  the  poison  from  a  dog  through  a  succession  of 
rabbits,  until  the  incubation  period  is  shortened  from  three  weeks  to 
seven  days.  When  the  virus  has  reached  its  maximum  intensity, 
it  is  called  virus  fixe,  in  contradistinction  to  the  virus  in  accidentally 
infected  animals,  whose  strength  is  not  known.     The  spinal  cords 


GENERAL   CONDITIONS    AND    SPECIAL    INFECTIONS  1 85 

of  rabbits  which  ha\'e  died  after  inoculation  with  the  virus  fixe 
gradually  lose  their  virulence  by  drying,  until  at  the  end  of  fourteen 
days  they  are  practically  innocuous.  The  vaccine  consists  of  about 
I  cm.  of  the  spinal  cord  of  a  rabbit  killed  by  the  fixed  virus,  emulsified 
with  5  c.c.  of  sterile  broth  or  salt  solution.  About  3  c.c.  of  this  emul- 
sion are  used  as  an  injection  twice  a  day.  On  the  firstd  ay  3  c.c.  of  a 
fourteen  day  cord  and  3  cc.  of  a  thirteen  day  cord  are  injected,  and  the 
strength  is  gradually  increased,  until  on  the  eighteenth  day  2  c.c.  of  a 
three  day  cord  are  used.  In  bites  about  the  head  and  face,  in  which 
the  period  of  incubation  is  shorter,  the  virulency  of  the  injections 
may  be  increased  more  rapidly.  If  the  patient  lives  within  a  day's 
journey  of  a  reliable  Pasteur  Institute,  the  virus  may  be  sent  to  him 
by  mail  and  injected  by  the  family  physician.  Of  104,347  cases  in 
which  the  Pasteur  treatment  has  been  used,  but  .73  per  cent, 
developed  hydrophobia  (Bernstein).  Very  rarely  (.048  per  cent,  of 
the  cases)  a  localized  or  an  ascending  paralysis  develops  during  the 
treatment,  and  this  possibility  should  be  explained  to  those  who  insist 
on  taking  the  antirabic  treatment  in  the  absence  of  evidence  that  the 
biting  animal  w^as  rabid  (Fielder).  The  serum  of  artificially  immun- 
ized sheep  has  been  recommended,  both  for  prophylactic  and  cura- 
tive purposes,  but  has  apparently  never  been  used  in  man.  After  the 
symptoms  have  once  appeared,  chloroform,  chloral,  and  morphin 
should  be  employed,  and  the  patient  carefully  guarded  from  all 
forms  of  irritation. 

Pseudohydro phobia,  or  lyssophohia,  is  a  mLxture  of  hysteria  and 
fright,  and  is  invariably  followed  by  recovery. 

ANTHRAX 

Anthrax  {malignant  pustule,  wool-sorter^ s  disease,  splenic  fever, 
charbon,  Milzhrand)  is  an  acute  infectious  disease  occurring  in 
animals,  particularly  cattle,  and  occasionally  communicated  to  man. 
Dogs,  cats,  pigs,  the  majority  of  birds,  and  cold  blooded  animals 
are  naturally  immune  to  anthrax  The  disease  is  common  in 
Russia,  Hungary,  and  certain  parts  of  France  and  Germany,  and 
comparatively  infrequent  in  England  and  the  United  States.  It  is 
caused  by  the  anthrax  bacillus,  a  non-motile,  facultative  anaerobe  with 
square  or  shghtly  cupped  ends,  which  is  equal  in  length  to  the  diam- 
eter of  a  red  blood  corpuscle  or  even  longer,  and  which  has  a  tendency 
to  form  chains.  When  cultivated  outside  the  body  it  forms  spores, 
which  have  the  greatest  resistance  to  all  forms  of  antiseptics.  The 
'  bacillus  is  found  in  local  lesions,  in  the  circulating  blood,  and  in  tjie 


1 86  MANUAL  OF  SURGERY 

various  organs  of  the  body.  In  animals  it  enters  the  body  through 
the  gastrointestinal  tract  with  the  food.  ^Slore  rarely  the  lungs  are 
infected  by  inhalation.  In  man  the  organism  usually  lodges  in  a 
wound  or  abrasion,  although  the  gastrointestinal  and  pulmonary 
varieties  may  occur.  The  bacilH  may  be  conveyed  by  flies,  and  by 
catgut  prepared  from  diseased  animals.  Farmers,  butchers,  veter- 
inary surgeons,  and  those  who  handle  hides,  wool,  horsehairs,  and 
similar  animal  products,  are  predisposed  to  the  disease.  Shaving 
brushes  and  fur  boas  also  have  been  responsible  for  infection. 

In  external  anthrax,  the  usual  lesion  in  man.  the  symptoms 
appear  in  from  one  to  five  or  six  days  or  even  longer.  The  character 
of  the  local  lesion  largely  depends  upon  the  structure  of  the  part; 
thus  in  dense,  highly  vascular  tissue  anthrax  carbuncle,  or  malignant 
pustule,  results,  and  in  lax  parts,  with  a  poorer  blood  supply,  an- 
thrax edema  occurs.  Malignant  pustule  (Fig.  74  )  begins  as  a  small, 
red.  burning  or  itching  pimple,  capped  by  a 
vesicle,  which  rapidly  grows  in  size.  The  sur- 
rounding tissues  become  red  and  infiltrated,  and 
a  secondary  ring  of  vesicles  develops  around  the 
primary  vesicle,  which  soon  bursts  and  turns 
black,  forming  a  tenacious  slough;  in  the  mean- 
time the  lymphatic  glands  enlarge  and  grow 
tender.  The  process  may  be  arrested  at  this 
point,  the  slough  separating  and  the  resulting 

Fig.    74. — Anthrax        i  i        t         i  i      •  a       i 

pustule  on  the  arm  of  ulccr  hcahng  by  granulation.  Anthrax  edema  is 
hi^s^  ^^°  -worked  in  characterized  by  a  rapidly  spreading,  livid  edema, 
which  is  associated  with  vesicles  filled  with  dark 
bloody  serum,  and  followed  by  gangrene  of  the  skin  and  subcutan- 
eous tissues.  In  cither  form  of  external  anthrax  pain  is  shght  and 
suppuration  absent,  and  in  many  instances  the  constitutional  symp- 
toms are  few  and  mild.  When  the  process  spreads  and  bacteremia 
develops,  there  are  symptoms  of  general  intoxication,  such  as  high 
temperature,  rapid  pulse,  vomiting,  embarrassed  respiration,  and  de- 
lirium, the  patient  dying  in  from  one  to  seven  days  from  the  onset. 
Internal  anthrax  also  occurs  in  two  forms.  In  intestinal  anthrax 
there  are  vomiting  and  blood  stained  diarrhea;  in  the  pulmonary 
form  co.ugh,  rapid  respiration,  cyanosis,  and  physical  signs  of  pneu- 
monia; the  symptoms  in  either  instance  rapidly  progressing  to 
collapse  and  death. 

The  diagnosis  should  always  be  confirmed  by  bacteriological 
examination.  Ordinary  carbuncle  is  distinguished  from  anthrax 
by  the  presence  of  pain,  numerous  points  of  suppuration,   and  a 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 87 

chronic  course.  The  sj)rea(Hn<^  forms  of  cellulitis  differ  from  anthrax 
edema  by  the  greater  pain,  the  marked  tendency  to  sui)puration. 
and  the  absence  of  the  characteristic  adherent  sloughs.  The  prog- 
nosis of  external  anthrax  is  more  favorable  in  the  carbuncular  form 
than  in  anthrax  edema.  The  mortality  is  from  lo  to  25  per  cent. 
Recover}'  is  rare  after  infection  of  the  lungs  or  intestinal  canal. 

The  treatment  is  excision  whenever  possible,  the  resulting  wound 
being  cauterized  with  pure  carbolic  acid  followed  by  alcohol,  with 
the  actual  cautery,  or  with  nitric  acid.  In  other  cases  free  incisions 
should  be  made,  and  bichlorid  of  mercury,  i  to  1000,  iodin,  i  to  2  in 
water,  or  carbolic  acid,  2  or  3  per  cent.,  injected  into  and  around  the 
infected  tissues.  The  wound  should  be  dressed  with  wet  bichlorid  com- 
presses, I  to  1000.  Ipecac  has  been  used  locally  and  internally.  The 
constitutional  treatment  is  that  of  septicemia.  The  patient  should 
be  isolated,  dressings  burned,  and  discharges  disinfected.  After 
removal  of  the  patient ^a  room  should  undergo  the  most  rigid  disin- 
fection, owing  to  the  great  resistance  of  the  spores.  Very  favorable 
results  have  been  reported  from  the  use  of  Sclavo's  serum,  which  is 
made  by  immunizing  asses  with  attenuated  cultures  of  the  bacillus; 
30  to  40  c.c.  are  injected  into  the  flank  in  three  or  four  different 
places,  or  in  severe  cases  directly  into  a  vein.  Kraus  administers 
from  10  to  50  c.c.  of  normal  bovine  serum  subcutaneously,  the  serum 
first  being  raised  twice  to  56°  C.  for  one-half  hour;  of  140  patients 
thus  treated  only  one  died.  Cattle  are  protected  from  anthrax  by 
inoculating  them  with  a  virus  weakened  by  heat. 

GLANDERS 

Glanders  {Farcy,  Equinia,  Malleus)  is  an  infectious,  contagious 
disease  occurring  in  animals,  particularly  horses,  asses,  and  mules, 
and  occasionally  transmitted  to  man.  The  specific  organism,  the 
bacillus  mallei,  is  an  amotile,  facultative  anaerobe,  looking  somewhat 
like  the  tubercle  bacillus.  It  gains  entrance  to  the  tissues  through  a 
wound  or  abrasion  of  the  skin,  or  through  the  unbroken  mucous 
membrane  of  the  conjunctivae  or  respiratory  passages.  The  period 
of  incubation  is  four  or  five  days.  Glanders  may  be  acute  or  chronic, 
and  is  characterized  by  the  development,  under  the  skin  or  mucous 
.  membrane,  of  nodules  that  suppurate  and  give  rise  to  ulcers,  which 
may  burrow  deeply  and  attack  the  bone.  These  nodules  may  be 
scattered  also  in  the  various  viscera.  The  term  farcy  is  sometimes 
restricted  to  the  cutaneous  form,  when  the  nodules,  which  develop 
chiefly  along  the  lymph  vessels,  are  called  "farcy  buds."     The  con- 


1 88  MANUAL  OF  SURGERY 

stitutional  symptoms  are  those  of  septicemia.  Death  may  occur 
within  a  week  in  acute  glanders.  In  the  chronic  form  the  lesions  are 
more  circumscribed  and  develop  more  slowly,  recovery  occurring 
in  50  per  cent,  of  the  cases. 

Diagnosis. — Acute  glanders  may  be  mistaken  for  such  suppura- 
tive affections  as  small-pox,  although  the  lesions  are  deeper  and 
there  is  absence  of  umbilication.  In  the  ulcerative  stage  it  may  be 
confused  with  syphilis  or  tuberculosis.  In  doubtful  cases  a  history 
of  exposure  to  infection,  a  bacteriological  examination,  and  inocula- 
tion of  the  pus  into  a  guinea-pig  will  settle  the  diagnosis.  In  ani- 
mals mallein,  a  bacterial  product  made  like  tuberculin,  is  injected 
subcutaneously,  causing  fever  and  localized  swelling  if  glanders  is 
present. 

Preventive  treatment  consists  in  the  destruction  of  infected 
animals.  In  man  nodules  are  extirpated,  ulcers  curetted  and  disin- 
fected, and  abscesses  opened  and  cauterized.  The  constitutional 
treatment  is  that  of  septicemia. 

ACTINOMYCOSIS 

Actinomycosis  is  an  infectious  disease,  occurring  principally 
in  cattle  {lumpy  jaw),  and  occasionally  in  man.  The  cause  is  the 
ray  fungus,  or  actinomyces,  which  belongs  to  the  streptothrices,  a 
group  of  micro-organisms  lying  between  the  moulds  and  bacteria. 
It  is  anaerobic,  and  occurs  in  clumps  consisting  of  a  central  mass, 
with  radiating  threads  or  myceha  with  club-hke  ends.  The  ray 
fungus  is  widely  distributed  in  nature,  but  is  most  frequently 
found  in  various  forms  of  grain,  from  which  it  enters  the  tissues 
through  the  respiratory  tract  (e.g.,  by  inhahng  dust  during  the 
grinding  of  corn),  through  the  alimentary  tract  (from  the  chewing 
of  raw  grain),  or  through  an  abrasion  or  wound  of  the  skin. 

Pathologically  the  process  resembles  a  chronic  inflammation, 
which,  owing  to  the  abundant  round-celled  infiltration  and  prolifer- 
ative changes  in  the  connective  tissue  cells,  forms  tumor-Hke  masses. 
The  ray  fungus  is  probably  not  pyogenic,  but  suppuration  is  prone 
to  occur,  as  the  result  of  secondary  infection  with  pus  germs.  The 
disease  occurs  most  frequently  in  the  lower  jaw  and  adjacent  tissues, 
less  frequently  in  the  respiratory  tract  and  intestines,  and  rarely 
in  the  skin. 

The  symptoms  are  those  of  a  firm  and  painless  swelling  that 
gradually  increases  in  size  and  finally  breaks  down  at  various  points, 
giving  rise  to  sinuses  that  discharge  pus  having  a  pecuhar  earthy 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 89 

odor  and  containing  minute,  gritty,  sulphur-yellow  bodies,  which 
under  the  microscope  are  found  to  be  masses  of  actinomycetes. 
The  lymphatic  glands  are  not  at  first  involved,  but  may  become 
so  later,  owing  to  mixed  infection,  which  is  responsible  also  for 
the  constitutional  symptoms.  The  process  spreads  from  its  point 
of  origin,  involving  tissues  by  contiguity  irrespective  of  their  struc- 
ture. Rarely  it  may  break  into  a  vein,  causing  a  general  dissemi- 
nation of  the  actinomycetes  (actinomycotic  pyemia).  If  all  the 
organisms  are  discharged  by  suppuration,  spontaneous  recovery 
may  occur;  indeed  this  may  happen  in  portions  of  the  mass,  giving 
a  nodular  and  puckered  appearance,  which  has  been  regarded  as 
almost  pathognomonic.  When  involving  the  cervico-facial  region 
trismus  is  frequently  seen.  The  prognosis  is  favorable  if  the  disease 
is  so  situated  as  to  be  accessible  to  surgical  treatment,  and  exceed- 
ingly unfavorable  in  regions  like  the  internal  organs,  in  which  it 
cannot  be  completely  eradicated,  death  occurring  from  exhaustion 
or  sepsis. 

The  treatment  is  excision,  if  the  lesion  be  small;  in  other  cases 
the  sinuses  should  be  widely  opened,  curetted,  swabbed  with  tincture 
of  iodin  or  cauterized  with  pure  nitrate  of  silver,  and  packed  with 
iodoform  gauze.  The  constitutional  treatment  consists  in  the 
use  of  large  doses  of  iodid  of  potassium,  which  is  given  for  one  week, 
then  discontinued  for  three  or  four  days,  and  given  for  another 
week.  The  interruptions  allow  resistant  spores  to  develop  into 
adult  forms,  when  they  are  more  readily  destroyed  by  the  drug. 
Iodid  of  potassium  in  i  per  cent,  solution  may  be  used  as  an  injection 
into  and  around  the  focus  of  infection.  The  X-rays  also  have  been 
used. 

MYCETOMA   OR  MADURA  FOOT 

Mycetoma,  or  madura  foot,  is  an  infectious  disease,  almost 
invariably  attacking  the  foot,  and  occurring  most  frequently  in 
India  and  rarely  in  America.  The  disease  is  closely  related  to 
actinomycosis,  being  caused  by  the  streptothrix  madurcE.  Following 
an  injury  to  the  foot,  there  develops  a  nodular  inflammatory  swelling 
that  breaks  down  and  forms  sinuses  discharging  a  watery  pus, 
which  contains  masses  of  the  organism  in  the  form  of  whitish  or 
black  granules.  In  the  former  instance  the  disease  is  called  pale, 
or  ocliroid,  in  the  latter  black,  or  melanoid  mycetoma.  The  foot 
becomes  greatly  enlarged  and  deformed,  and  the  leg  atrophied.  In 
very  early  cases  the  area  may  be  excised;  later  amputation  is  the 
only  treatment. 


I  go  MANUAL    OF    SURGERY 

LEPROSY 

Leprosy  (lepra,  elephantiasis  Grcecorum)  is  an  infectious 
and  feebly  contagious  disease  caused  by  the  bacillus  leprce.  which 
closely  resembles  the  tubercle  bacillus,  though  it  is  more  readily 
stained  and  less  frequently  curved.  Excepting  some  of  the  Gulf 
states  and  portions  of  the  Pacific  coast,  leprosy  is  ver>^  rare  in  the 
United  States,  but  is  common  in  Mexico,  South  America.  Norway 
and  Sweden,  and  in  the  Orient.  It  occurs  in  two  forms,  the  tuber- 
cular and  the  anesthetic,  which  are  often  associated.  The  period 
of  incubation  is  generally  from  three  to  five  years.  Tuberculated, 
or  cutaneous  leprosy,  occurs  most  frequently  on  the  face,  hands, 
feet,  and  extensor  surfaces  of  the  elbow's  and  knees.  After  a  period 
of  feverishness  with  digestive  disturbances,  there  appear  httle 
hyperemic  nodules,  which  may  disappear  only  to  reappear.  Later 
the  redness  fades  and  the  nodules  increase  in  size,  occasionally 
becoming  as  large  as  a  hen's  egg.  and  break  down  to  form  indolent 
ulcers,  or  are  converted  into  contracting  cicatricial  tissue,  which 
causes  hideous  deformities,  that  of  the  face  being  characteristic 
{leotitiasis  leprosa);  the  mucous  membranes  and  the  viscera  like- 
wise may  be  involved,  and  there  is  atrophy  of  the  testicles  or  ovaries 
with  loss  of  sexual  power.  Anesthetic,  or  nervous  leprosy,  begins 
with  neuralgia  and  tenderness  of  certain  peripheral  nerves,  most 
frequently  the  median,  ulnar,  saphenous,  and  peroneal.  Later 
there  are  anesthesia,  paralysis,  and  trophic  disturbances,  the  last 
involving  the  bones,  joints,  and  muscles,  as  well  as  the  skin,  and 
producing  great  deformity.  Whitish  or  browmish  spots  appear 
on  the  skin,  and  gradually  grow  larger  and  coalesce.  As  the  result 
of  injuries  to  the  anesthetic  areas,  various  secondary  infections 
may  occur,  producing  widespread  ulceration,  or  even  gangrene 
(lepra  mutilans).  Death  occurs  in  from  one  to  twenty  years, 
from  exhaustion,  or  from  some  compHcation.  not  uncommonly 
tetanus  or  tuberculosis. 

The  treatment,  in  addition  to  isolation  of  the  patient,  is  symp- 
tomatic, no  specific  drug  being  known.  Of  the  many  remedies  which 
have  been  tried,  chaulmoogra  oil.  15  to  20  drops  daily,  on  bread, 
seems  to  be  the  most  beneficial.  Oudin  is  a  warm  advocate  of 
radiotherapy.  In  the  very^  earhest  stages  excision  of  the  diseased 
areas  may  be  considered.  In  the  anesthetic  variety  nerve  stretching 
has  been  recommended.  Ulcers,  gangrene,  etc.,  are  treated  accord- 
ing to  general  surgical  principles;  amputations  and  other  operations 
may  be  required,  the  wounds  in  such  cases  healing  without  mishap. 


GENERAL    COXDITIOXS    AXD    SPECIAL    INFECTIONS  IQI 

SYPHILIS 

Syphilis  is  a  iiighly  contagious  disease  due  to  the  spirochela 
(treponema)  pallida  (Schaudinn  and  Hoffman),  an  actively  motile. 
unicellar,  spiral  parasite  (probably  a  protozoon),  varying  from 
4  to  14m  in  length,  and  possessing  pointed  ends  and  from  3  to 
12  curves.  The  spirocheta  may  be  found  in  the  primary  and  in  all 
secondary  lesions,  also  in  the  blood,  urine,  saliva,  lymph  glands, 
and  internal  organs.  It  has  been  found  in  small  numbers  in  gum- 
mata  and  in  large  numbers  in  still-born  syphilitic  fetuses.  It  has 
been  cultivated  in  artificial  media  (Noguchi)  and  produces  syphilis 
in  apes,  from  the  lesions  of  which  it  can  again  be  recovered. 

Methods  of  Infections. — Excepting  (i)  " concepiional  syphilis,'' 
in  which  a  mother  is  contaminated  by  a  syphihtic  fetus  (the  father 
having  the  disease)  through  the  placental  circulation,  acquired 
syphilis  is  always  (2)  initiated  by  a  chancre,  the  result  of  infection 
of  an  abrasion  or  other  solution  of  continuity  of  an  epithelial  surface, 
usually  of  the  genital  organs  during  sexual  intercourse.  Syphilis 
insontium  is  a  term  applied  to  the  disease  innocently  acquired,  the 
chancre  in  these  cases  often  being  extragenital,  e.g.,  on  the  lip  from 
the  use  of  an  infected  glass  or  pipe.  The  disease  may  be  carried 
by  a  third  person  who  does  not  acquire  the  disease;  thus  an  uncleanly 
surgeon  may  convey  the  virus  on  his  finger  from  one  patient  to 
another.  Congenital,  or  hereditary  syphilis,  does  not  present  a 
chancre;  it  is  (i)  the  result  of  syphiUs  in  one  or  both  parents  previous 
to  conception,  or  (2)  of  infection  through  the  placenta  in  case  the 
mother  acquires  the  disease  subsequent  to  conception.  ''Accidental 
inoculations,  conjugal  syphilis,  and  hereditary  syphilis  together 
far  outnumber  the  venereal  cases"  (Post).  ''In  1080  patients 
in  the  Johns  Hopkins  dispensary,  without  reference  to  w^hat  disease 
they  came  for  (genitourinary  cases  excepted),  there  were  10.8  per 
cent  who  gave  a  positive  Wassermann"  (Walker).  The  disease  is  ac- 
tively contagious  for  several  years,  i.e.,  during  the  primary  and  second- 
ary stages.  When  the  tertiary  stage  has  been  reached  the  disease  is 
said  to  be  no  longer  contagious,  although  the  organisms  have  been 
demonstrated  in  the  lesions.  The  germ  of  syphilis  is  difficult  to 
kill,  thus  a  w^ound  will  frequently  be  the  site  of  a  chancre  though 
carefully  disinfected  within  even  a  few  hours  after  its  infection. 
The  views  concerning  immunity  to  syphilis  have  been  revolution- 
ized since  the  discovery  of  the  Wassermann  reaction.  It  was 
formerly  taught  that  one  attack  of  the  disease  conferred  immunity 
against  subsequent  attacks,  that  a  woman  might  have  a  syphihtic 


192  MANUAL    OF    SURGERY 

husband  and  syphilitic  children  without  becoming  tainted  {Colles' 
immunity),  and  that  healthy  children  might  be  born  to  syphilitic 
parents  {Prof eta's  immunity).  It  is  now  known  that  in  all  these 
instances  the  so-called  immunity  is  not  immunity,  but  insusceptibility 
due  to  latent  syphilis,  as  the  individuals  in  question  react  to  the 
laboratory  tests  for  syphilis.  In  other  words,  immunity  to  syphilis 
does  not  exist,  and  this  means,  if  we  are  to  believe  the  arsphenamin 
enthusiasts,  that  reinfection,  which  was  very  rare  with  the  older 
forms  of  treatment,  because  the  patients  were  not  cured,  will 
become  much  more  frequent  after  the  recoveries  that  are  now  being 
obtained  with  arsphenamin. 

The  period  of  incubation  is  from  one  week  to  three  months,  the 
average  being  twenty-one  days.  During  this  time  the  breach  of 
surface  through  which  the  organism  has  entered  the  body  heals 
and  no  signs  of  trouble  are  manifest,  unless  there  has  been  at  the 
same  time  infection  with  chancroidal  or  pyogenic  bacteria. 

The  disease  itself  is  divided  into  three  stages:  The  primary 
stage  comprises  the  chancre  and  indolent  bubo.  The  time  elapsing 
between  the  appearance  of  the  chancre  and  the  second  stage,  usually 
about  six  weeks,  is  called  the  period  of  secondary  incubation.  The 
second  stage  consists  principally  of  superficial  lesions  of  the  skin 
and  mucous  membranes.  It  lasts  from  one  to  three  years,  and  is 
followed  by  recovery,  or  by  a  latent  or  intermediate  period,  lasting 
from  a  few  months  to  many  years  (usually  two  to  four  years),  in 
which  the  symptoms  are  slight  or  absent.  The  third  stage,  the 
duration  of  which  is  indefinite,  consists  of  gummatous  degeneration 
or  diffuse  sclerotic  changes  in  various  parts  of  the  body.  In  some 
cases  the  secondary  merges  with  or  overlaps  the  tertiary  stage,  so 
that  no  distinct  line  can  be  drawn  between  them. 

The  typical  chancre,  or  initial  lesion,  begins  as  a  minute,  erythe- 
matous, painless  papule,  which,  as  it  enlarges,  becomes  indurated 
and  loses  its  epithelial  covering,  appearing  as  a  round,  oval,  or 
Hnear  erosion,  whose  center  is  covered  by  a  grayish,  glistening  film, 
and  whose  border  is  the  color  of  raw  muscle.  Suppuration  is 
slight  or  absent,  the  discharge  being  scanty,  thin,  and  watery. 
Chancre  is  usually,  but  not  invariably,  single.  When  multiple  all 
the  chancres  appear  at  the  same  time,  as  the  infection  is  not  auto- 
inoculable.  A  chancre  does  not  always  present  the  same  appear- 
ance, being  modified  according  to  its  situation  and  the  presence  or 
absence  of  complications,  which  are  rare.  On  the  skin  a  chancre 
not  exposed  to  maceration  or  irritation  does  not  ulcerate,  or  at  most 
simply  desquamates,  forming  a  scab.     When  subjected  to  irritation 


GENERAP    CONDITIONS    AND    SPECIAL    INFECTIONS 


193 


or  maceration  it  ulcerates  {Hunterian,  or  ulcerative  chancre),  then 
being  oval  or  round  with  sloping  edges.  The  characteristic  features 
of  a  chancre  may  be  masked  by  the  presence  of  phagedena  or  other 
forms  of  infection;  in  a  "mixed  cliancre"  in  which  chancroidal  and 
syphilitic  organisms  are  both  present,  the  diagnosis  can  rarely  be 
made  from  appearances  alone.  The  induration  of  a  chancre,  which 
is  due  to  sclerosis  of  the  blood  vessels  and  hyperplasia  of  the  con- 
nective tissue  cells,  is  circumscribed  and  of  the  consistency  of  hard 
rubber  or  cartilage,  but  varies  in  thickness  according  to  the  struc- 
ture of  the  affected  part;  thus  on  the  glans  penis  it  may  feel  like  a 
piece  of  paper  {foliaceous  induration)  or  a  visiting  card  (parchment 
induration),  while  in  laxer  tissues  it  is  greater  in  extent  and  may 
feel  like  a  foreign  body  in  the  tissues  (nodular  induration).  In  rare 
cases  induration  does  not  occur  for  several  weeks  after  the  appear- 
ance of  ulceration;  in  fact,  in  very  rare  instances  it  may  never  occur. 
With  the  healing  of  the  chancre  (usually 
in  from  four  to  six  weeks)  the  indura- 
tion gradually  disappears,  but  if  origin- 
ally extensive,  it  may  still  be  detected 
for  months  or  years.  Little  or  no  scar 
results,  unless  the  corium  has  been  de- 
stroyed by  ulceration.  Ulceration  or 
reinduration  at  the  site  of  the  original 
chancre  (chancre  redux)  may  occur  after 
years  as  the  result  of  reinfection  (very 
rare)  or  gummatous  degenerat  on.  The 
most  frequent  situation  of  chancre  in  the  male  is  the  balanopreputial 
fold, in  the  female  the  inner  surface  of  the  labia  majora.  Fournier, 
however,  has  seen  chancre  on  every  part  of  the  body  except  the  sole 
of  the  foot.  A  chancre  may  be  easily  overlooked,  e.g.,  when  on  the 
OS  uteri,  when  of  the  non-ulcerating  or  desquamating  variety,  and 
when  situated  in  some  extragenital  region. 

The  syphilitic  bubo  (satellite  bubo)  is  a  constant  consort  of  the 
chancre,  appearing  with  its  induration.  The  enlarged  glands 
appear  in  the  groin  when  the  lesion  is  upon  the  external  genitals, 
in  the  submaxillary  region  when  on  the  lip,  and  in  the  axilla  when 
on  the  breast  or  hand.  They  are  (i)  small,  (2)  non-inflammatory 
(painless,  freely  movable,  not  covered  by  adherent  or  reddened 
skin,  and  do  not  suppurate),  (3)  hard  (induration  of  the  chancre 
transferred  to  the  lymphatic  glands),  and  (4)  polygangUonic  (pleiad 
of  Ricord),  feehng  hke  a  group  of  almonds  (amygdaloid)  beneath 
the  skin.     An  inflammatory  bubo  the  result  of  any  other  form  of 

13 


Fig.  75. — Chancre  of  arm. 


194  "  MANUAL    OF    SURGERY 

infection,  including  chancroid  and  gonorrhea,  pursues  an  acute 
course,  with  pain,  greater  swelling,  immobility  of  the  glands,  ad- 
herent and  reddened  skin,  boggy  induration,  edema,  and  eventual 
suppuration,  and  does  not  respond  to  syphilitic  treatment. 

The  diagnosis  of  chancre  may  be  confirmed  (i)  by  finding  the 
spirocheta  pallida  in  the  discharge;  (2)  by  the  Wassermann  (or 
Noguchi)  serum  reaction,  which  appears  during  the  first  two  weeks 
after  the  chancre  in  50  per  cent,  of  the  cases,  increases  gradually 
in  frequency  up  to  the  fourth  or  fifth  week,  when  it  may  be  obtained 
in  from  80  to  90  per  cent,  of  the  cases,  disappears  when  recovery 
takes  place,  when  the  disease  becomes  inactive,  and  when  the 
patient  is  saturated  with  antisyphilitic  remedies,  and  which  is 
present  only  occasionally  in  other  conditions  (yaws,  leprosy,  noma, 
narcosis,  pellagra,  scarlatina,  pneumonia,  tuberculous  cachexia, 
Hodgkin's  disease,  myeloid  leukemia,  recurrent  fever,  lead  poisoning, 
sleeping-sickness);  (3)  by  the  therapeutic  test  (i.e.,  prompt  response 
to  antisyphilitic  treatment);  or  (4)  by  waiting  for  secondary  symp- 
toms. If  one  can  have  the  laboratory  tests,  mentioned  above,  made 
there  can  be  no  excuse  for  waiting  until  the  secondary  symptoms 
appear  before  making  a  diagnosis.  If  the  Wassermann  test  is  nega- 
tive, the  spirochetes  can  be  found  in  the  chancre;  the  tests  are  sup- 
plementary. It  may  be  that  the  luetin  test,  described  by  Noguchi, 
also  will  prove  an  important  diagnostic  aid.  Noguchi  says  it  is  of  the 
greatest  value  in  tertiary  and  latent  syphilis,  while  the  Wassermann  re- 
action is  more  constant  in  primary  and  secondary  syphiHs.  Extra- 
genital chancres  occur  most  frequently  about  the  mouth  (20 per  cent.), 
breasts  (10  per  cent.),  and  anus,  and  are  usually  larger,  but  less 
indurated,  than  the  genital  chancre.  The  discharge  is  more  profuse, 
the  base  of  the  ulcer  covered  with  a  dirty  membrane  or  scab,  the 
adjacent  lymph  glands  are  apt  to  be  larger  and  more  tender,  and 
the  constitutional  symptoms  more  severe.  Of  particular  interest 
to  surgeons  and  obstetricians  is  chancre  of  the  finger,  which  is  fre- 
quently mistaken  for  a  whitlow,  as  it  is  often  accompanied  by 
considerable  pain  and  discharge.  It  is  distinguished  by  its  sharp 
circumscription,  dense  induration,  long  duration,  failure  to  react  to 
antiseptic  treatment,  and  by  enlargement  of  the  epitrochlear  gland. 

Chancroid  has  an  incubation  of  from  one  to  five  days,  is  rarely 
seen  except  on  the  glans  penis  or  prepuce,  commences  as  a  pustule 
or  ulcer,  is  frequently  multiple,  and  is  autoinoculable;  it  is  usually 
irregular  in  shape,  punched  out,  and  excavated,  with  a  dirty  yellow- 
ish, uneven  base  and  a  copious  purulent  discharge;  if  induration  is 
present,  it  is  softer  than  that  of  chancre,  fades  off  gradually  into 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  1 95 

the  surrounding  tissues,  and  disappears  with  the  heahng  of  the 
ulcer;  it  is  painful,  does  not  confer  immunity  against  a  second  at- 
tack, is  more  frequently  complicated  by  extensive  ulceration  and 
suppurative  bubo,  is  healed  by  local  measures  and  uninfluenced 
by  antisyphilitic  treatment,  and  the  bacillus  of  Ducrey  may  be 
found  in  the  discharge.  In  all  cases  search  should  be  made  for 
the  spirochetes,  a  Wassermann  test  made  and,  if  negative,  repeated 
at  the  end  of  the  third  and  sixth  weeks,  and  the  patient  watched 
for  two  months  for  signs  of  secondary  syphilis. 

Herpetic  ulceration  about  the  genitals  follows  fevers,  neuralgia, 
or  irritation  from  dirt  or  discharges,  and  has  no  period  of  incubation. 
It  commences  as  a  number  of  vesicles,  which  may  run  together, 
forming  a  large  irregular  ulceration  whose  edges  are  made  up  of 
segments  of  circles.  The  discharge  is  purulent  but  not  abundant, 
vesicles  w^hich  have  not  burst  may  be  found,  bubo  is  commonly 
absent,  the  ulceration  is  painful,  superficial,  not  indurated,  and  it 
heals  under  local  treatment. 

Urethral  chancre  may  be  mistaken  for  urethritis.  The  period  of 
incubation  of  chancre  is  over  ten  days,  that  of  urethritis  under  one 
week.  In  chancre  the  pain  is  felt  only  at  the  meatus,  in  urethritis 
it  extends  along  the  whole  urethra;  chordee  is  absent  in  the  former, 
present  in  the  latter.  The  discharge  in  chancre  is  scanty,  serous, 
and  sometimes  bloody;  in  urethritis  it  is  profuse,  purulent,  and 
less  frequently  blood  stained.  The  characteristic  induration  may 
be  felt,  and  superficial  ulceration  seen,  in  chancre,  generally  in  one 
of  the  lips  of  the  meatus.  The  bubo  of  chancre  is  constant  and 
practically  never  suppurates;  in  urethritis  bubo  is  absent,  or,  if 
present,  usually  suppurates.  Chancre  is  followed  by  constitutional 
symptoms,  which  are  absent  in  urethritis.  Microscopic  examination 
of  the  discharge  may  reveal  the  spirocheta  or  the  gonococcus  and 
the  blood  should  be  examined  for  the  Wassermann  reaction. 

Labial  chancre  may  be  confused  with  epithelioma.  Chancre  in 
this  region  shows  no  marked  preference  for  either  sex;  it  may  be  seen 
on  either  lip  and  is  more  frequent  in  the  young.  The  general  health 
is  unafifeGted  and  pain  is  shght  or  absent.  The  ulcer  is  smooth, 
and  has  elevated,  sloping,  regular  borders,  a  glistening  or  varnished 
base,  and  the  sharply  defined,  characteristic  induration;  it  matures 
in  two  or  three  weeks.  Enlargement  of  the  submaxillary  glands  is 
usually  found  from  the  beginning,  a  history  of  exposure  to  syphilis 
may  be  obtained,  and  the  diagnosis  may  be  corroborated  -^by 
finding  the  spirochetge,  by  the  Wassermann  and  therapeutic 
tests,    or,   when    these    tests    are    not    available,    by    waiting    for 


196  MANUAL    OF    SURGERY 

the  secondary  symptoms.  Epithelioma  is  more  frequent  in  males 
(20  to  i),  is  practically  always  upon  the  lower  lip,  is  seen  after 
middle  life,  affects  the  general  health,  and  may  be  painful;  the  bor- 
ders are  irre^^ular,  thickened,  and  everted,  and  the  base  is  covered 
with  scabs,  removal  of  which  discloses  bleeding,  fungous  granula- 
tions; the  induration  is  not  as  hard  as  that  of  chancre  and  grad- 
ually diffuses  into  the  surrounding  tissues;  the  ulcer  requires  months 
for  its  development,  the  submaxillary  glands  are  usually  not  palpable 
for  four  or  five  months  or  even  longer,  a  history  of  chancre  in  youth 
may  be  obtained,  the  growth  is  uninfluenced  by  antisyphilitic 
treatment,  secondary  symptoms  do  not  occur,  and  microscopical 
examination  will  give  the  picture  of  epithelioma. 

Tuberculous  ulceration  of  the  tongue  is  distinguished  from  chancre 
by  the  presence  of  the  lesion  on  the  inferior  surface  of  the  tongue 
(chancre  being  more  frequent  on  the  dorsum) ,  and  the  presence  of 
several  ulcers;  by  its  greater  extent,  deeper  invasion,  irregular  out- 
line, steep  or  undermined  borders,  yellowish  uneven  base,  absence  of 
induration,  excessive  pain,  and  yellowish  tubercles;  by  the  absence 
of  secondary  symptoms  of  syphilis,  of  the  spirocheta,  and  of  the 
Wassermann  reaction,  and  the  failure  of  antiluetic  remedies;  and 
by  the  diagnostic  methods  given  under  tuberculosis. 

The  secondary  stage  of  syphilis  consists  of  lesions  of  the  skin 
(syphilides) ,  mucous  membranes  (mucous  patches),  appendages  of 
the  skin  (onychia,  paronychia,  alopecia),  enlargement  of  the  lymph 
glands  in  different  parts  of  the  body,  neuralgic  pains,  inflammation 
and  thickening  of  the  periosteum,  arthropathies,  iritis  (rarely  other 
forms  of  eye  disease),  epididymitis,  and  interference  with  the  general 
health  (fever,  anemia,  disorders  of  digestion)  and  with  the  process 
of  reproduction.  Retinitis,  choroiditis,  affections  of  the  acoustic 
nerve,  and  meningitis  are  being  reported  with  increasing  frequency, 
as  secondary  manifestations  whether  as  the  result  of  arsphen- 
amin  treatment  or  more  careful  observation  is  a  matter  of  dispute. 
During  this  period  the  disease  is  not  serious  for  the  patient, 
but  is  dangerous  for  those  with  whom  he  comes  in  contact  and  for  his 
offspring.  Abortion  is  frequent,  or  if  the  child  goes  to  term,  it  is  apt 
to  die  soon  after  birth.  The  lesions  during  this  period  are  widely 
scattered,  almost  always  superficial,  and  tend  toward  recovery  even 
without  treatment. 

The  first  symptom  may  be  the  rash  on  the  skin,  fever,  or  neuralgic 
pains.  The  ''fever  of  eruption'''  is  usually  trivial  and  falls  with  the 
development  of  the  eruption;  syphihtic  fever  occurring  later  may  be 
intermittent,  remittent,  or  continuous,  and  has  been  mistaken  for 


GENERAL    CONUITIONS    AND    SPECIAF,    INFECTIONS  IQ7 

such  diseases  as  rheumatism,  malaria,  and  tyjjhoid  fever.  With  the 
onset  of  secondary  symptoms  the  lymphatic  glands  all  over  the  body 
enlarge  and  assume  the  features  of  the  original  bubo.  The  post- 
cervical,  submental,  and  epitrochlear  glands  are  of  diagnostic  value, 
because  they  are  seldom  enlarged  from  local  pyogenic  infection. 
The  blood  contains  the  organism,  and  shows  a  slight  increase  in  the 
number  of  white  cells,  particularly  of  the  lymphocytes,  with  a 
diminution  in  the  number  of  red  cells  and  the  amount  of  hemoglobin. 

Syphilides  generally  appear  in  from  six  to  seven  weeks  after  the 
appearance  of  the  chancre,  occasionally  earlier,  and  sometimes, 
notably  when  mercurial  treatment  has  been  administered  from  the 
beginning,  not  for  several  months.  The  secondary  skin  rashes 
(syphilodermata)  may  (i)  ape  any  form  of  cutaneous  eruption,  but 
are  always  an  imperfect  counterfeit;  they  are  (2)  often  apyretic, 
(3)  slow  in  evolution,  (4)  non-inflammatory,  (5)  seldom  itching 
or  painful,  (6)  often  of  a  ham  or  copper  color,  (7)  apt  to  occur  in 
circles  or  segments  of  circles,  and  (8)  when  affecting  the  extremities 
most  frequent  on  the  flexor  surfaces  (which  includes  the  sole  of  the 
foot  and  the  palm  of  the  hand) ;  (9)  they  tend  to  recover,  and  are 
(10)  superficial,  (11)  piofuse,  (12)  disseminated,  (13)  polymorphous, 
(14)  symmetrical,  and  (15)  desquamating;  (16)  syphilis  in  other 
parts  of  the  body  may  exist,  (17)  the  rash  responds  to  antisyphilitic 
treatment,  (18)  the  Wassermann  test  may  be  positive,  and  perhaps 
(19)  the  spirocheta  may  be  found.  The  features  ot  the  tertiary 
syphilides  are  listed  under  the  "Tertiary  Stage." 

The  chief  varieties  of  the  syphilides,  progressing  from  the  early  and 
superficial  to  the  late  and  deep,  are  as  follows:  i.  Erythema  (diffuse 
redness)  or  roseola  (maculae  or  spots)  occurs  principally  upon  the 
trunk ;  there  is  no  elevation  of  the  surface  and  the  redness  disappears 
upon  pressure.  2.  Papules  may  be  small  and  miliary  (syphilitic 
lichen)  or  large  (occasionally  four  or  five  inches  in  diameter); 
they  may  desquamate  {papulo-squamoiis  syphilides),  or  in  moist 
regions,  as  about  the  genitals,  they  may  become  excoriated  {moist 
papules,  mucous  patches  of  the  skin,  or  flat  condylomata).  Papulo- 
squamous syphilides  upon  the  palms  and  soles  are  called  palmar  and 
plantar  psoriasis;  papules  on  the  forehead  the  corona  Veneris;  and 
when  the  size  of  lentils  lenticular  papules.  3.  Vesicles  rarely  form  in 
syphilis,  but  a  herpetiform  syphilide  is  described.  4.  Pustules  SLiise 
from  breaking  down  papules,  hence  syphilitic  acne  when  the  apex  of 
the  papule  suppurates,  syphilitic  impetigo  when  the  whole  papule 
breaks  down,  and  syphilitic  ecthyma  or  rupia  when  the  true  skin  is 
deeply  invaded.     In  rupia  successive  layers  of  scabs  form  resembling 


igS  MANUAL    OF    SURGERY 

an  oyster  shell.  In  ecthyma,  if  a  scab  forms,  it  is  easily  detached, 
exposing  a  punched  out  ulcer  surrounded  by  a  red  zone  of  hyperemia. 
5.  Tubercular  syphilides  are  large  papules  or  small  gummata.  6. 
Besides  these  tj^pes  of  eruption,  discoloration  of  the  skin,  peculiarly 
of  the  neck,  may  occur  {pigmentary  syphilides). 

The  mucous  tuembranes  are  affected  somewhat  like  the  skin. 
The  sore  throat  of  secondary  syphilis  consists  of  a  reddening  of  the 
fauces  or  tonsils,  which  is  sharply  limited,  reniform  in  shape,  and 
often  followed  by  ulceration,  the  ulcerated  area  being  shallow  with  a 
grayish  color  and  steep  edges.  Mucous  patches  are  papules  due  to  the 
overgrowth  of  papillae,  which,  owing  to  the  sodden  condition  of  the 
epithelium,  are  white  in  color;  they  are  circular  or  oval  in  outline, 
may  progress  to  ulceration,  originate  a  highly  contagious  discharge, 
and  are  commonly  seen  in  the  mouth  and  about  the  anus  and  genitals. 
Condylomata  are  large  tubercles  due  to  hypertrophy  of  papillae; 
they  look  somewhat  like  warts,  often  appear  in  cauliflower-like 
masses,  and  occur  most  frequently  about  the  anus  and  genitals. 
Eruptions  or  inflammations  in  the  larynx  produce  syphilitic  hoarse- 
ness, in  the  ears  transient  deafness. 

Syphilitic  alopecia  is  usually  detected  at  the  time  of  the  sore 
throat  and  skin  eruptions.  It  may  involve  the  head  alone  or  the 
entire  body.  It  occurs  as  a  general  thinning  of  the  hair  or  in  irregu- 
lar patches.  The  skin  is  apt  to  be  scaly.  As  the  folhcles  are  not 
destroyed,  the  hair  is  usually  reproduced. 

The  nails  may  be  shed  owing  to  inflammatien  of  the  matrix 
{onychia),  or  the  skin  around  the  base  of  the  nail  may  be  inflamed  or 
ulcerated  (paronychia). 

The  bones  in  various  regions  may  be  the  seat  of  fugitive  pains, 
which  are  usually  more  severe  at  night  (osteocopic  pains).  Nodes 
due  to  periostitis  may  form,  especially  on  the  skull,  clavicle,  and 
tibia.     In  the  joints  a  symmetrical  synovitis  may  be  noticed. 

Syphilitic  iritis  makes  its  appearance  in  from  three  to  six  months 
after  the  chancre.  It  affects  one  eye  at  first,  but  is  very  apt  to 
spread  to  the  other.  There  are  pain,  impairment  of  vision,  photo- 
phobia, lachr}Tnation,  a  pericorneal  zone  of  hyperemia,  often  a 
change  in  color  of  the  iris,  blurring  and  irregularity  of  the  pupil, 
which  is  usually  small  and  fails  to  react  to  atropin. 

Syphilitic  epididymitis  may  occur  late  in  the  secondary  period, 
and  consists  of  gummatous  nodules  which  are  quickly  dispersed  by 
proper  treatment;  it  may  affect  one  or  both  sides.  Syphilitic  orchitis 
{syphilitic  sarcocele)  is  a  diffuse  sclerosis  of  the  testicle  itself  and 
belongs  to  the  tertiary  period. 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  199 

111  tlie  intermediate  period  the  symptoms  may  be  latent,  or  there 
may  be  ''reminders,"  such  as  the  syj)hili(k's,  principally  syi)hilitic 
psoriasis,  and  epididymitis.  Rctino-choroidilis  and  cndarlerili s  may 
occur,  the  latter  producing  various  forms  of  paralysis,  owing  to 
anemia  of  the  motor  centers. 

The  tertiary  stage  is  characterized  by  diffuse  sclerosis  or  gumma- 
tous degeneration  of  any  part  of  the  body.  As  in  the  secondar\- 
stage,  the  blood  shows  a  slight  leukocytosis  without,  however,  so 
distinct  a  lymphocytosis.  The  lesions  are  discrete,  widely  separated, 
and  larger  and  less  common  than  in  the  secondary  stage;  they  are 
often  serious  to  the  patient  but  not  to  others.  Although  any 
of  the  syphilides  may  occur,  the  cutaneous  eruptions  are  almost 
always  tubeicular  oi  gummatous.  The  tertiary  resemble  the  second- 
ary syphihdes  except  in  the  following  particulars:  They  involve 
the  whole  thickness  of  the  skin,  do  not  so  readily  respond  to  treat- 
ment, appear  irregularly,  tend  strongly  to  ulcerate  and  spread,  and 
are  monomorphous,  asymmetrical,  irregular  in 
distribution,  and  not  so  widely  disseminated. 
The  ulcers  are  excavated,  having  sharply  cut 
or  undermined  edges  and  a  ragged  base;  they 
are  painless,  circular^  or  semilunar  in  shape, 
often  covered  by  thick  crusts  or  a  tough,  ad-  pj^  76— Ulcerating 
herent,  dirty  yellow  slough,  and  are  not  apt  to    gumma  of  hand.    Note 

.  punched  out  appearance. 

enlarge  the  lymphatic  glands;  they  leave  perma- 
nent scars  which  are  smooth,  white,  and  depressed  below  the  level 
of  the  surrounding  skin.  Tertiary  ulcers  may  take  on  a  phagedenic 
action,  boring  deeply  into  the  tissues,  or  eating  along  the  surface  in 
circles  or  undulating  lines  {serpiginous).  Severe  tertiary  are  said  to 
follow  mild  secondary  symptoms,  and  mild  tertiary,  violent  second- 
ary symptoms. 

In  diffuse  sclerosis  chronic  inflammatory  changes  are  followed  by 
hyperplasia  of  the  fibrous  tissue,  giving  rise  to  endarteritis,  and 
disease  of  the  testicle  (sarcocele),  liver,  spleen,  kidneys,  heart, 
nervous  system,  and  other  tissues  or  organs. 

The  gumma  is  a  nodular  mass  consisting  of  prohferated  con- 
nective tissue  cells,  leukocytes,  and  sometimes  giant  cells,  which, 
owing  to  the  thickening  of  the  blood  vessels  and  the  cutting 
ofif  of  the  blood  supply,  undergoes  necrotic  changes  {fatty  or 
gummatous  degeneration) .  With  proper  treatment  this  mass  may 
be  absorbed,  or  the  necrotic  tissue  becomes  semi-fluid  and  breaks 
through  the  skin,  leaving  a  circular  ulcer  with  red,  undermined 
edges,  and  a  characteristic,  dirty,  yellowish-white,  adherent  slough 


200  MAIvUAL    OF    SURGERY 

(Fig.  76).  In  some  of  the  internal  organs,  such  as  the  brain,  testicle, 
and  liver,  the  necrotic  tissue  may  become  encysted  and  calcified. 
Gummata  may  be  single  or  multiple.  Occasionally,  instead  of  a 
well  localized  nodule,  there  may  be  a  diffuse  gummatous  degenera- 
tion of  a  considerable  area.  The  scars  resulting  from  gummata, 
when  situated  in  a  canal  of  the  body,  may  produce  stricture. 

Parasyphilis  and  metasyphilis  are  terms  applied  to  what  some  call 
the  guarternary  stage,  in  which  lesions  of  the  skin  (e.g.,  leukoderma), 
of  the  mucous  membranes  (e.g.,  leukoplakia),  of  the  nervous  system 
(e.g.,  tabes  and  dementia  paralytica),  and  of  other  structures  may 
occur,  lesions  which  are  the  result  of  syphilis,  but  are  no  part  of  the 
disease  itself,  as  they  do  not  react  to  specific  treatment. 

Tertiary  lesions  affecting  special  structures  are  noticed  in  subse- 
quent pages  as  occasion  demands. 

The  diagnosis  of  tertiary  lesions  is  made  (i)  by  the  local  features 
mentioned  above;  (2)  by  the  history,  in  the  taking  of  wh'*ch,  if 
chancre  is  denied,  one  should  inquire  particularly  whether  there  has 
been  transient  loss  of  hair,  sore  throat  or  mouth,  skin  rashes,  and  in 
women  frequent  miscarriages;  (3)  by  evidences  of  previous  syphilis, 
e.g.,  periosteal  nodes  (especially  on  the  skull,  clavicle,  and  tibiae), 
iritis,  old  scars,  and  patches  of  induration  on  the  genitals;  (4)  by  the 
therapeutic  test,  which  is  not  always  reliable;  (5)  by  the  Wassermann 
reaction;  and  possibly  (6)  by  recovery  of  the  spirocheta  and  (7)  the 
luetin  test.  In  all  stages  of  syphilis  a  negative  may  frequently  be 
converted  into  a  positive  Wassermann  reaction  by  the  injection  of 
arsphenamin,  the  blood  being  examined  not  later  than  48  hours 
after  the  injection;  this  "provocative  Wassermann"  is  of  most 
service  in  the  diagnosis  of  tertiary  lesions. 

In  syphilis  of  the  nervous  system  the  cerebrospinal  fluid  may 
give  a  positive  Wassermann  reaction,  even  though  the  blood  test 
is  negative.  In  these  cases  cytological  and  chemical  examination 
of  the  fluid  may  give  additional  information  (see  "Spinal  Puncture"). 

The  prognosis  of  syphihs  is  favorable  if  proper  treatment  be 
administered  in  the  early  stages  for  a  sufiiciently  long  period,  it  being 
generally  believed  that  cure  will  result  in  the  large  majority  of  these 
cases.  When  the  disease  comes  under  observation  late,  when  the 
patient  fails  to  carry  out  the  treatment,  when  there  is  an  associated 
general  disease,  notably  tuberculosis,  often  the  best  that  can  be  done 
is  to  keep  the  disease  under  control.  Some  cases  seem  to  be  malig- 
nant and  do  not  recover  though  proper  treatment  be  given  from  even 
the  beginning.  A  patient  should  not  be  permitted  to  marry  until 
the  disease  is  cured,  i.e.,  absence  of  symptoms  and  of  the  Wassermann 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  20I 

reaction  for  at  least  one  year  after  the  cessation  of  treatment,  and 
never  within  four  years  of  the  chite  of  the  chancre. 

The  best  prophylactic  measure,  according  to  Metschnikoff,  is  the 
rubbing  of  calomel  ointment  (calomel  ;^;^,  lanolin  67)  into  the  site  of 
inoculation;  this  is  said  to  prevent  chancre  if  performed  within  18 
hours  of  the  intercourse  (cf.  "Proj^hylaxis  of  Gonorrhea").  The 
treatment  of  the  disease  itself  consists  in  the  employment  of  mercury, 
or  of  arsphenamin  and  mercury,  during  the  primary  and  secondary 
stages,  and  of  mercury  and  iodids,  with  or  without  arsphenamin, 
during  the  tertiary  stage.  Mercury  and  arsphenamin  are  spiro- 
cheticides;  the  iodids  attack  the  granulomatous  tissue  of  the  gumma, 
thus  liberating  the  spirochetes  and  rendering  them  vulnerable  to 
mercury  and  arsphenamin.  In  view  of  the  difficulty  of  making  a 
positive  diagnosis  from  the  appearance  of  the  chancre  alone,  many 
surgeons  used  to  withhold  constitutional  treatment  until  the  appear- 
ance of  secondary  symptoms.  Now  in  even  the  earliest  stages  a 
positive  diagnosis  can  be  reached  by  the  detection  of  the  spirocheta 
and  the  Wassermann  reaction. 

In  employing  mercury  some  prefer  intermittent  treatment,  believing 
that  after  a  time  the  drug  ceases  to  be  effective  and  the  tissues  need 
a  rest.  Protiodid  of  mercury,  grain  }i,  is  given  daily  for  six  months, 
then  a  rest  of  a  month  is  taken,  and  treatment  again  given  for  three 
months,  nine  months  of  treatment  being  given  during  the  first  year, 
and  eight  months  during  the  second.  In  the  continuous  method 
protiodid  of  mercury,  grain  }i,  is  given  in  pill  form  three  times  a  day 
after  meals,  the  dose  being  increased  one  pill  each  day,  so  that  on  the 
second  day  the  patient  takes  %,  on  the  third  i  grain,  and  so  on,  until 
the  gums  become  tender,  the  breath  fetid,  and  the  bowels  loose. 
The  dose  is  then  cut  in  half  and  the  patient  kept  on  this  for  two 
years.  If  in  the  absence  of  other  symptoms  diarrhea  tends  to  per- 
sist, opium,  grain  3^12,  may  be  added  to  each  pill.  Any  of  the  other 
preparations  of  mercury  may  be  used  in  a  similar  way.  When 
mercury  is  not  well  borne  by  the  stomach,  it  may  be  used  by  inunc- 
tion, I  dram  of  the  ointment  being  rubbed  into  a  dififerent  portion  of 
the  body  each  day,  so  as  to  avoid  irritation  of  the  skin;  the  method  is 
highly  efficacious  but  dirty.  Intramuscular  injections  are  often 
painful,  and  sometimes  produce  inflammation,  necrosis,  or  embolism. 
They  may  be  indicated  when  a  very  rapid  effect  is  desired,  e.g.,  when 
a  lesion  is  on  the  face  or  threatens  life;  or  when,  owing  to  gastrointes- 
tinal irritation,  mercury  cannot  be  administered  by  mouth  and,  at 
the  same  time,  inunctions  cannot  be  given.  Many  prefer  the  insolu- 
ble preparations,  as  they  are  /absorbed  slowly,  hence  need  be  given 


2C2  MANUAL    OF    SURGERY 

only  at  comparatively  long  intervals.  Five  minims  of  a  mixture  of 
calomel  i  and  albolin  4.  lo  minims  of  a  mixture  of  salicylate  of  mer- 
cury I  and  albolin  10.  or  10  minims  of  gray  oil  may  be  injected  once  a 
week.  The  site  of  injection  must  be  recorded,  because  if  symptoms 
of  salivation  appear  it  will  be  necessary  to  excise  the  tissues  contain- 
ing the  unabsorbed  portion  of  the  drug.  Bichlorid  of  mercury 
is  the  soluble  salt  usually  employed.  The  ordinary  dose  is  from 
H2  to  li  of  a  grain.  ''This  is  injected  daily,  since  absorption  is 
rapid,  and  must  be  repeated  in  appropriate  doses  until  the  symptoms 
disappear,  after  which  it  is  continued  in  series  of  six  doses  with  inter- 
vals of  six  days'  rest  for  the  first  year,  and  in  series  of  three  doses 
with  intervals  of  nine  days'  rest  for  the  second  year,  the  quantity 
being  increased  or  diminished  in  accordance  with  the  clinical  indica- 
tions" f Martin).  The  injections  are  made  deeply  into  the  muscles 
of  the  back  or  the  buttocks,  selecting  a  new  site  for  each  injection, 
and  using  a  needle  with  a  large  lumen  if  an  insoluble  salt  is  em- 
ployed. In  order  to  avoid  embolism,  the  needle,  unattached  to  the 
syringe,  should  first  be  introduced,  and  allowed  to  remain  a  short 
time,  to  see  if  it  has  entered  a  vein.  Mercury  has  been  used  also  by 
fumigation;  a  diam  of  calomel  is  volatilized  from  a  water  bath,  which 
is  placed  under  a  cane  seat  chair  upon  which  the  patient  sits  naked, 
the  fumes  being  confined  by  a  blanket  which  reaches  from  the  pa- 
tient's neck  to  the  floor.  In  somewhat  the  same  way  mercury  has 
been  introduced  into  the  body  through  the  skin  by  means  of  baths 
(Hg  CI2  5ss  to  a  bath-tub  full  of  water),  in  which  the  patient  lies  for 
an  hour  or  longer.  J ntravenous  injections  should  not  be  employed. 
In  all  cases,  at  least  during  the  early  stages,  the  patient  should  be 
seen  frequently,  or  cautioned  as  to  symptoms  of  mercurialism  (hy- 
drargyrism,  ptyalism.  salivation),  which,  owing  to  idiosyncrasy,  may 
rapidly  follow  even  small  doses.  The  gums  become  soft,  spongy, 
tender,  and  bleed  easily;  there  is  an  excessive  production  of  thick 
saliva,  with  fetid  breath,  metalhc  taste  in  the  mouth,  colicky  pain  in 
the  abdomen,  and  diarrhea.  In  more  severe  cases  the  teeth  loosen, 
the  alveolar  process  becomes  necrotic,  and  severe  ulceration  of  the 
mouth  develops.  Chronic  mercurialism  is  manifested  by  digestive 
disorders,  sahvation.  loss  of  weight,  albuminuria,  mental  depression, 
tremor,  and  general  weakness.  These  symptoms  may  be  prevented 
by  careful  regulation  of  the  dose  of  mercury,  by  having  the  teeth  put 
in  order,  by  cleansing  the  mouth  several  times  a  day  with  tooth 
powder  and  tooth  brush,  by  the  use  of  a  mouth-wash  containing 
chlorate  of  potash,  and  by  prohibiting  the  use  of  tobacco.  Saliva- 
tion is  treated  bv  discontinuing  the  mercurv.  bv  giving  a  saline 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  203 

purge,  and  by  the  use  of  antiseptic  and  astringent  mouth-washes. 
Albuminuria  calls  for  an  intermission  or  a  great  reduction  in  the  dose 
of  the  mercury. 

The  general  health  should  not  be  neglected,  and  if  neces.sary 
tonics  should  be  employed.  The  contagious  nature  of  the  malady 
should  be  impressed  upon  the  patient,  who  should  be  directed  to 
have  separate  eating  and  toilet  utensils,  to  avoid  kissing,  to  sleep 
alone,  and  to  bathe  frequently,  paying  special  attention  to  naturally 
moist  parts  of  the  body,  such  as  the  axillae  and  the  perineum.  At 
the  end  of  two  years  the  patient  should  take  mixed  treatment  (hy- 
drarg.  chlor.  cor.  g.  i,  potassium  iodid  5  ss,  syrup  sarsaparillae  comp. 
f5iii-f  oi.  in  water  after  meals)  for  six  months  or  longer,  or  if  there 
have  been  symptoms,  the  mixed  treatment  should  continue  for  six 
months  from  the  last  symptom. 

The  lesions  of  tertiary  syphilis  are  controlled  by  mixed  treatment. 
The  mercury  is  used  for  its  antisyphilitic  action  and  the  iodids  for 
the  absorption  of  gummatous  tissue.  Iodid  of  potassium  or  sodium 
may  be  given  in  a  saturated  watery  solution,  each  drop  of  which 
contains  i  grain  of  the  iodid.  It  is  customary  to  begin  with  5  or  lo 
drops  of  this  solution  in  plenty  of  water  after  meals,  and  increase  the 
dose  I  drop  each  day,  until  in  some  intractable  cases  as  much  as  60 
or  more  grains  a  day  are  given.  Toxic  effects  are  manifested  by 
coryza.  fetid  breath,  disorders  of  digestion,  and  cutaneous  eruptions 
(acne,  vesicles,  bullae).  The  iodid  should  be  discontinued  and 
elimination  stimulated.  Belladonna  and  arsenic  have  been  used  to 
prevent  the  skin  eruptions. 

Arsphenamin  {saharsan,  Ehrlich's  "606")  is  a  yellowdsh  powder 
containing  34.16  per  cent,  arsenic,  the  chemical  name  being  dioxy- 
diamidoarsenobenzoldihydrochlorid.  It  is  given  subcutaneously, 
intramuscularly,  rectally,  or,  as  preferred  by  most  syphilographers, 
intravenously.  At  first  one  dose  was  thought  to  be  sufficient  to  effect 
a  cure.  Relapses  followed,  however,  and  now  it  is  customary  to 
repeat  the  injections  once  a  week  for  six  or  eight  weeks,  giving  at 
the  same  time  a  course  of  mercury,  which  consists  of  inunctions  of 
the  ointment  every  day,  of  the  injection  of  a  soluble  salt  every  day  or 
two  days,  or  of  the  interjection  of  an  insoluble  salt  once  a  week.  A 
rest  of  six  weeks  in  then  taken,  and  the  arsphenamin  and  mercurial 
courses  repeated.  In  primary  syphilis  this  may  be  sufficient  to 
abort  the  disease,  but  the  patient  should  be  watched  for  at  least  a 
year,  and  the  blood  tested  every  month  or  two  during  this  period. 
In  secondary  syphilis  at  least  three  courses  of  arsphenamin  with 
mercury  should  be  administered,  and  if  a  positive  VVassermann  test 


204  MANUAL    or    SURGERY 

or  other  evidences  of  syphilis  continue  the  courses  may  be  repeated 
at  intervals  of  six  or  eight  weeks.  In  latent  lues  more  benefit  is 
derived  from  the  old-fashioned  mixed  treatment  than  from  arsphe- 
namin  alone  or  combined  with  potassium  iodid  (Fordyce).  In 
syphiHs  of  the  nervous  system  the  Swift-ElHs  method  is  often  em- 
ployed. This  consists  in  giving  arsphenamin  intravenously,  and 
after  one  hour  withdrawing  from  20  to  30  c.c.  of  blood,  from  which 
the  serum  is  separated.  From  10  to  15  c.c.  of  this  medicated  serum 
are  injected  into  the  subarachnoid  space,  after  performing  a  spinal 
puncture  and  allowing  an  equivalent  amount  of  the  cerebrospinal 
fluid  to  escape.  The  simplest  method  of  preparing  the  drug  for 
injection  is  that  of  Alt,  slightly  modified.  The  powder,  which  comes 
in  glass  ampoules  containing  0.6  gram,  the  average  dose,  is  shaken 
with  30  c.c.  of  warm  normal  salt  solution,  in  a  glass-stoppered  bottle, 
until  dissolved.  About  2  c.c.  of  normal  sodium  hydroxid  solution 
is  then  added.  This  precipitates  a  yellowish  sediment,  which  is 
redissolved  by  adding  more  of  the  sodium  hydroxid  solution,  drop 
by  drop,  until  the  fluid  is  clear.  If  the  intravenous  route  is  chosen, 
enough  salt  solution  should  be  added  to  bring  the  quantity  up  to 
250  c.c.  A  large  vein  is  made  prominent  by  compression,  punctured 
with  a  platino-iridum  needle,  and,  after  a  few  drops  of  blood  have 
escaped,  the  needle  attached  by  means  of  a  rubber  tube  to  a  gradu- 
ated glass  reservoir  containing  salt  solution.  As  soon  as  the  salt 
solution  begins  to  flow  into  the  vein,  the  rubber  tube  is  pinched,  the 
salt  solution  poured  from  the  reservoir,  and  the  prepared  salvarsan 
introduced.  The  drug  must  be  prepared  immediately  before  injection 
and  should  not  be  given  to  those  with  nonsyphilitic  organic  diseases, 
especially  of  the  kidneys,  heart,  blood  vessels,  optic  or  auditory 
nerves,  or  central  nervous  system,  or  to  those  who  have  previously 
had  arsenical  treatment  or  who  possess  an  idiosyncrasy  to  arsenic. 
The  patient  may  be  kept  in  bed  for  24  hours  after  the  injection. 
Intravenous  injections  may  be  followed  by  a  chill  or  by  thrombosis, 
subcutaneous  and  intramuscular  injections  by  a  painful  induration 
or  sloughing,  and  all  methods  of  administration  by  fever,  vomiting, 
and  watery  stools.  The  Jarisch-Herxheimer  reaction  is  an  intensi- 
fication of  the  symptoms  of  syphilis  sometimes  observed  after  the 
administration  of  arsphenamin  or,  to  a  less  extent,  mercury.  Among 
the  more  serious  symptoms  which  have  been  noted  after  the  injec- 
tion of  arsphenamin  are  blindness,  deafness,  hematemesis,  melena, 
multiple  neuritis,  intractable  dermatitis,  albuminuria,  vesical  paraly- 
sis, irregularity  of  the  heart,  jaundice,  and  convulsions.  A  number 
of    deaths  following  injection  have  been  reported,   and  no  doubt 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  205 

there  are  a  number  which  have  not  been  reported.  It  is  not  possible 
at  the  i)rcsent  time  to  determine  the  real  value  of  "606";  some  think 
it  a  specific  which  will  cure  in  a  few  doses,  others  that  it  is  not  su- 
perior to  mercury.  It  is  possible,  however,  to  decide  that  it  is  a 
very  powerful  drug  capable  of  producing  alarming  symptoms  and 
even  death,  that  it  is  still  in  the  experimental  stage,  and  that  it 
should  be  used  with  great  caution  and  only  by  those  who  have 
learned  the  technic  of  administration  from  the  experienced. 
Perhaps  less  dangerous  arsenical  preparations,  given  more  often 
and  in  small  doses,  will  prove  to  be  as  efificient  even  if  slower. 
Murphy  has  obtained  remarkable  results  with  sodium  cacodylate, 
which  may  be  given  in  doses  of  3^^^  to  2  grains,  in  pills,  hypodermic- 
ally,  or  by  enema,  repeated  at  intervals  of  three  or  four  days. 

N eoarsphenamin  (ncosalvarsan)  is  "a  very  soluble  form  of  arsphe- 
namin  obtained  by  the  addition  of  formaldehydsulphoxylate  of  soda. 
It  is  claimed  to  be  fully  as  efficacious  as  the  old  remedy  and  possesses 
certain  decided  advantages  in  the  simplification  of  the  technic  of 
its  preparation  and  the  greater  tolerance  to  it,  permitting  much 
larger  doses  at  shorter  intervals.  It  is  extremely  soluble  in  water. 
Neutralization  with  caustic  soda  is  not  necessary  as  with  old  arsphe- 
namin,  as  the  new  product  is  neutral  when  in  solution.  It  is  pre- 
pared by  dissolving  0.15  gm.  in  20  c.c,  or  1.5  gm.  in  200  c.c.  of  freshly 
distilled  water;  0.8  gm.  in  2  2  c,c.  gives  an  isotonic  solution."  Since  stale 
water  or  saline  solution  may  contain  molds  or  saprophytic  bacteria 
which  can  give  rise  to  foreign  protein  reactions  with  symptoms 
resembling  acute  arsenical  poisoning,  only  freshly  distilled  and 
sterilized  water  should  be  used. 

"As  the  preparation  oxidizes  readily  and  the  oxidation  products 
are  more  toxic  than  the  drug  itself,  the  following  precautions  are 
suggested:  In  making  the  mixture  it  should  be  gently  agitated  and 
not  vigorously  shaken.  It  should  not  be  warmed  after  it  is  made  up, 
and  it  must  be  used  immediately.  Four  doses  are  administered  in 
succession  with  an  interval  of  one  day  between.  Schreiber's  pro- 
cedure is  to  give  0.9  gm.  for  the  first  dose,  1.2  gm.  for  the  second, 
1.35  gm.  on  the  third  day  and  1.5  gm.  on  the  fourth.  This  equals  6 
gm.  of  ncosalvarsan  or  4  gm.  of  salvarsan  within  one  week.  Women 
receive  from  0.75  to  1.2  gm.,  children  0.15  to  0.35  and  infants  0.05 
gm.  In  cases  of  meningitis  or  involvement  of  the  cerebrospinal 
system  the  patient's  susceptibility  should  be  cautiously  tested  with 
small  doses.  Owing  to  its  less  irritating  properties  ncosalvarsan 
lends  itself  more  readily  to  intramuscular  use.  For  this  purpose  0.9 
gm.  are  dissolved  in  about  30  c.c.  of  water.     Several  c.c.  of  a  i  per 


2o6  MANUAL    OF    SURGERY 

cent,  novocain  solution  are  lirst  injected;  the  needle  is  left  in  situ-> 
and  the  neosalvarsan  injected  through  it  several  minutes  later. 
Schreiber  has  observed  edema  after  its  use,  but  never  infiltration  or 
necrosis.     He  prefers,  however,  the  intravenous  method"  (Fordyce). 

Local  treatment  in  syphiUs  is  of  secondary  importance.  Excision 
of  the  chancre  is  not  recommended  by  most  surgeons,  as  it  has  no 
influence  on  the  general  symptoms.  As  pointed  out  by  Martin, 
however,  excision  must  remove  a  quantity  of  the  infective  material, 
and  it  provides  a  bit  of  tissue  from  which  a  diagnosis  can  be  made. 
If  the  chancre  is  not  excised  it  should  be  cleansed  by  immersion  in  a 
I  to  500  bichlorid  of  mercury  solution  and  dusted  with  an  antiseptic 
powder.  Syphilitic  buboes  require  no  local  treatment,  unless  they 
suppurate  because  of  mixed  infection.  Mucous  patches  in  the 
mouth  and  syphihtic  sore  throat  may  be  touched  with  nitrate  of 
silver,  30  grains  to  the  ounce,  and  astringent  and  antiseptic  mouth 
washes  used;  mucous  patches  in  other  regions  and  condylomata 
should  be  disinfected  with  peroxid  of  hydrogen  and  bichlorid  of 
mercury  and  dusted  with  calomel.  Non-ulcerative  tertiary  lesions 
are  treated  by  the  application  of  mercurial  ointment.  Gummata 
should  not  be  opened,  even  when  fluctuating,  as  absorptijn  from 
the  internal  administration  of  potassium  iodid  is  still  possible. 
Ulcerating  gummata  should  be  kept  scrupulously  clean,  since  second- 
ary infection  may  make  them  exceedingly  foul,  inaugurate  a  phage- 
dena, or  markedly  interfere  with  their  healing.  In  some  of  these 
cases  hectic  fever  with  amyloid  degeneration  of  the  viscera  occurs. 

Congenital  or  inherited  syphilis  results  from  the  disease  in  either 
or  both  of  the  parents.  Formerly  it  was  thought  that  parents  who  had 
completed  the  secondary  stage,  i.e.,  after  three  or  four  years,  were  no 
longer  capable  of  transmitting  the  disease  to  their  offspring,  although 
exceptions  to  this  rule  were  noted,  and  that  it  was  possible  for  parents 
in  even  the  contagious  period  to  bring  forth  healthy  children.  It  is 
probable,  considering  the  observations  previously  made  on  immunity, 
that  in  most  of  these  cases  serologic  investigation  would  reveal  latent 
syphilis. 

Active  fetal  syphilis  generally  results  in  death  of  the  fetus  and 
abortion;  or  if  the  fetus  goes  to  term,  in  death  at  or  soon  after  birth. 
Although  infantile  syphilis  may  be  manifest  at  birth,  or  may  not 
show  itself  for  a  number  of  years,  the  first  symptoms  are  usually 
noticed  within  a  few  weeks  or  months  of  birth.  Any  of  the  lesions 
of  syphilis,  excepting,  of  course,  the  primary  chancre,  may  be  en- 
countered when  the  disease  is  inherited  and  the  spirochetae  have  been 
demonstrated  in  these  lesions.     Of  peculiar  diagnostic  value  are  the 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  20/ 

wrinkled,  shriveled  up,  old  man  appearance,  marked  anemia,  the 
hoarse  cry  due  to  inflammation  of  the  laryngeal  mucous  membrane, 
and  snuffles  due  to  inflammation  of  the  nasal  mucous  membrane. 
The  last  may  go  on  to  ulceration  and  be  associated  with  destruction 
of  the  nasal  bones  and  cartilages,  causing  a  falling  in  of  the  bridge 
of  the  nose  (Fig.  77).  The  spleen  and  liver  are  usually  enlarged. 
Mucous  patches  about  the  lips  may  leave  radiating  scars  (rhagades) , 
especially  at  the  angles  of  the  mouth  (Fig.  78).  Pemphigus,  partic- 
ularly on  the  palms  and  soles,  is  one  of  the  earliest  and  most  char- 
acteristic skin  eruptions.  Inflammation  and  thickening  at  the  epi- 
physeal junctions  of  the  long  bones,  and  periosteal  nodes,  which,  on 
the  cranium,  give  rise  to  the  natiform  skull  also  are  common.  Many 
die  during  this,  the  secondary  stage,  and  those  that  survive  may  pass 
through  an  intermediate  or  latent  period  of  variable  length,  some- 
times lasting  until  the  second  dentition,  puberty,  or  even  longer. 


Fig.   77. — Con^itnital  syphilis  showing       Fig.     78. — Congenital  syphilis  showing 
necrosis  of  skull  and  facial   bones    with         necrosis  of  facial  bones  and  rhagades. 
saddle  nose. 

Among  the  tertiary  phenomena  which  require  special  mention 
are  sudden  deafness  in  both  ears  without  pain  or  discharge,  inter- 
stitial keratitis  (cornea  has  a  ground-glass  appearance,  and  later  a 
salmon  color  due  to  vascularization,  both  are  usually  involved), 
Hutchinson  teeth  (the  permanent  upper  and  median  incisors  are 
dwarfed,  separated,  and  narrower  at  the  crown  than  at  the  root, 
the  cutting  edge  being  curved  with  the  convexity  upwards),  and 
dactylitis  (chronic  painless  enlargement  of  a  finger  or  toe,  due  to 
gummatous  infiltration  or  syphilitic  osteomyehtis — Fig.  76). 

The  treatment  should  be  not  only  antisyphilitic,  but  also  tonic, 
including  such  drugs  as  cod-liver  oil,  iodid  of  iron,  and  the  phos- 
phates. IMercury  is  best  administered  by  daily  rubbing  5  or  i  o  grains 
of  the  ointment  into  the  soles  of  the  feet,  or  by  placing  it  on  the 


208  MANUAL    OF    SURGERY 

inner  side  of  the  belly  band.  If  there  is  much  irritation  of  the  skin, 
hydrarg.  cum  creta,  grain  ^,  with  i  grain  of  sugar,  may  be  given 
three  times  a  day  after  nursing.  Potassium  iodid,  ^  to  i  grain,  in 
simple  syrup,  gradually  increased,  is  given  three  times  a  day  with 
the  onset  of  tertiary  symptoms.  The  treatment  should  be  continued 
for  at  least  two  years,  and  recommenced  at  each  outbreak  of  symp- 
toms. Arsphenamin  or  neoarsphenamin  also  may  be  administered.  In 
infants  blood  may  be  obtained  for  the  Wassermann  or  other  tests,  or 
intravenous  medication  given,  by  puncturing  the  superior  longitudinal 
sinus  with  a  hollow  needle,  which  is  inserted  in  the  posterior  part 
of  the  anterior  fontanel  in  the  midline  for  a  distance  of  }^{q  of  an 
inch,  the  point  being  directed  downward  and  backward. 

TUBERCULOSIS 

Tuberculosis  is  an  infectious  and  contagious  disease  caused  by 
the  bacillus  of  tuberculosis.  The  tubercle  bacillus  is  a  rod-shaped 
facultative  anaerobe,  measuring  fom  1.5/1  to  3.5^  in  length.  It  may 
be  straight  or  curved  and  is  frequently  seen  in  pairs;  it  is  non-motile 
and  probably  develops  only  in  living  tissues,  although  capable  of 
maintaining  its  vitality  for  a  long  time  outside  the  body.  Its  toxin 
is,  as  yet,  little  understood.  The  bacillus  enters  the  body  through 
external  wounds,  through  the  respiratory  tract,  through  the  alimen- 
tary canal  (infected  milk  or  meat),  or  in  the  fetus,  through  the 
placenta.  The  most  frequent  method  is  by  the  inhalation  of  dust, 
along  with  which  the  bacilli  are  carried.  Animal  tuberculosis 
differs  in  some  respects  from  human  tuberculosis,  but  is  probably 
only  a  modified  form  of  the  same  disease;  that  the  two  are  inter- 
communicable  seems  to  be  proved.  Tuberculosis  is  exceedingly 
common,  indeed  some  would  have  us  believe  that  we  all  are  in- 
fected. Xaegeli  found  tuberculosis  of  some  sort  in  97  per  cent, 
of  700  autopsies.  There  seems  to  be  no  way  to  avoid  taking 
these  organisms  into  the  body,  but  something  more  than  the 
tubercle  bacillus  is  required  for  the  development  of  the  disease,  viz. , 
inherited  susceptibility,  poor  food,  overcrowding,  depressed  vitality 
following  prolonged  illness  or  mental  strains,  or  local  injuries.  The 
disease  is  rarely,  but  the  predisposition  frequently,  transmitted  from 
parent  to  child.  Those  who  possess  this  predisposition  {strumous, 
scrofulous,  or,  better,  tuberculous  diathesis)  are  often  frail,  anemic, 
and  precocious;  the  skin  is  apt  to  be  delicate,  the  complexion  fair,  the 
hair  fine,  the  lashes  long,  the  head  large,  the  cranial  bones  promi- 
nent, the  nose  short  and  broad,  the  Hps  thick,  the  lower  jaw  small,  the 
muscles  soft,  the  bones  slender,  the  epiphyses  enlarged,  the  chest 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  209 

small  and  ilat;  and  there  is  frecjuently  a  tendency  to  eczema,  catar- 
rhal inflammation  of  the  mucous  membranes,  non-tuberculous 
enlargement  of  the  lymphatic  glands,  corneal  ulcers,  granular 
lids,  and  carious  teeth. 

Tuberculosis  may  occur  at  any  age,  and  in  any  portion  of  the 
body,  but  is  most  common  in  early  life  and  in  the  respiratory  tract, 
genitourinary  organs,  bones,  joints,  lymph  glands,  serous  mem- 
branes, brain,  liver,  and  spleen.  The  so-caWcd ''  sensilc  kiherculosis'^ 
presents  no  essential  difference  from  the  disease  in  the  young. 

Tuberculosis  is  characterized  by  the  formation  of  nodules  or 
tubercles,  which  vary  in  size  from  i  or  2  mm.  to  masses  as  large  as  a 
pea,  and  by  the  occurrence  of  inflammatory  changes  between  and 
around  these  tubercles;  in  truth,  the  inflammatory  changes  may 
constitute  the  whole  process,  the  tubercles  being  inconspicuous  or 
absent.  A  tubercle  is  formed  as  follows:  The  bacilli  lodge  in  the 
intimaof  the  small  vessels,  in  which  inflammatory  changes  occur,  lead- 
ing to  a  proliferation  of  the  endothelial  cells  (endarteritis),  and  sub- 
sequently to  a  proliferation  of  the  connective-tissue  cells  and  of  the 
leukocytes  which  have  wandered  from  the  bloodvessels;  thus  a  little 
mass,  or  tubercle,  is  formed,  which  is  grayish  in  color  and  more  or 
less  translucent.  A  typical  tubercle  contains  one  or  more  gianl 
cells,  which  are  due  to  the  fusion  of  epithehoid  cells  and  show  many 
nuclei;  surrounding  these  cells  are  the  epithelioid  cells  (proliferated 
connective-tissue  cells),  which  are  midway  in  size  between  the  giant 
cells  and  the  leukocytes  and  contain  a  single  nucleus;  the  outermost 
zone  is  made  up  of  proliferated  leukocytes  {lymphoid  cells).  The 
bacilli  may  be  found  in  the  giant  cells  and  occasionally  in  the  epithe- 
lioid cells.  The  giant  cell  is  by  no  means  characteristic  of  tuberculosis, 
as  it  is  found  in  many  other  pathological  conditions.  With  the 
onset  of  necrotic  changes  in  the  tubercle,  the  bacilH  are  no  longer 
demonstrable,  but  they  or  their  spores  are  undoubtedly  present,  for 
the  injection  of  such  material  into  guinea-pigs  produces  tuberculosis. 
As  the  vessel  from  which  it  started  becomes  obliterated  by  the 
proliferated  cells,  a  tubercle  is  avascular;  and  as  no  new  vessels  are 
formed  owing  to  the  anemia  and  the  specific  action  of  the  bacillus, 
degenerative  changes  occur.  There  is  at  first  a  hyaline  change,  then 
coagulation  necrosis,  next  fatty  degeneration,  and  finlly  the  produc- 
tion of  cheesy  material  {caseation,  or  caseous  necrosis) .  A  tubercle 
undergoing  caseation  is  called  a  yellow  or  crude  tubercle.  The  fate 
of  a  tubercle  is  largely  influenced  by  the  general  and  local  resist- 
ance of  the  tissue.  In  favorable  cases  it  may  undergo  atrophy  and 
completely  disappear,  or  become  encapsulated  by  dense  scar  tissue, 

14 


2IO  MANUAL    OF    SURGERY 

the  cheesy  material  either  being  absorbed  or  calcihed.  In  the  latter 
instance  the  healed-in  tuberculous  material  may  remain  latent  for  a 
long  time  and  again  be  awakened  to  activity.  In  unfavorable  cases 
the  caseous  material  liquifies, forming  tuberculous  pus  (see  "Chronic 
Abscess."). 

Tuberculosis  extends  by  continuit}-  or  contiguity  of  tissues, 
possibly  aided  by  the  ameboid  movements  of  the  leukocytes,  as  the 
bacillus  itself  is  non-motile;  in  other  instances  it  gains  entrance  to  the 
lymph  or  blood  stream  and  is  transported  to  distant  parts.  When 
the  bacilli  enter  the  blood  stream  and  produce  multiple  tubercles 
widely  distributed  throughout  the  body  {acute  generaU  or  military 
tuberculosis) .  a  tuberculous  pyemia  results,  a  condition  which  closely 
resembles  and  is  often  mistaken  for  typhoid  fever. 

The  diagnosis  may  be  considered  under  the  following  headings: 
(i)  The  history  of  a  family  predisposition,  of  previous  tuberculous 
lesions,  of  an  unfavorable  occupation,  of  unhygienic  surroundings,  of 
habitual  association  with  tuberculous  individuals;  (2)  general  symp- 
toms, such  as  weakness,  anemia,  loss  of  appetite,  indigestion,  pro- 
gressive loss  of  weight,  and  slight  afternoon  rise  in  the  temperature; 
(3)  the  type  of  patient  (vide  supra) ;  and  (4)  evidences  of  tuberculosis 
elsewhere  in  the  body  are  all  suggestive  but  not  conclusive.  (5)  The 
local  features,  which  will  be  described  in  connection  with  the  disease 
in  special  structures,  and  which  may  require  special  means,  e.g.,  the 
X-ray,  cystoscope,  etc.,  for  their  demonstration,  are  often  distinctive; 
sometimes  the  tubercles  can  be  seen.  The  insidious  onset,  marked 
chronicity,  and  tendency  to  recurrence  which  characterizes  most 
forms  of  surgical  tuberculosis  should  be  noted  in  this  place.  (6) 
Recovery  of  the  tubercle  bacillus  assures  the  diagnosis,  but  even  when 
these  are  not  demonstrable,  (7)  inoculation  of  a  guinea-pig  may 
result  in  generalized  tuberculosis.  C8)  Microscopic  examination  of 
the  diseased  tissues  will  usually  show  the  characteristic  structure  of 
the  tubercle.  (9)  Cytologic  examination  of  tuberculous  fluids  may 
reveal  an  excess  in  the  number  of  lymphocytes.  (10)  Blood  examina- 
tion may  show  a  relative  lymphocytosis.  Leukocytosis  and  iodo- 
philia  are  indicative  of  mixed  infection.  Tubercle  bacilli  are  rarely 
found  in  the  blood.  The  value  of  the  agglutination  test  is  doubtful. 
A  persistently  low  tuberculo-opsonic  power  of  the  blood,  according 
to  Wright,  means  tuberculosis.  (11)  The  tuberculin  test  may  be 
performed  in  four  ways:  (a)  subcutaneous  injection  causes,  in  a  tuber- 
culous subject,  a  reaction  which  consists  of  a  rise  of  temperature  of 
from  1°  to  3°,  and  a  general  feehng  of  illness,  occasionally  with  nausea 
and  vomiting.     The  tuberculous  lesion  itself  undergoes  inflammatory 


GENERAL    CONDITIONS    AND    SPECIAL    INFECTIONS  2  11 

changes.  The  method  should  rarely  be  emj)loyed,  because  of  the 
disagreeable  reaction,  the  possibility  of  stimulating  the  process  or  of 
inoculating  the  patient  with  tubercle  bacilli,  and.  because  of  the  un- 
certainty of  the  test  (the  margin  of  error  has  been  estimated  at  lo 
per  cent.)-  It  cannot  be  employed  when  the  patient's  temperature 
rises  to  or  above  ioo°  V.  The  dose  for  diagnostic  purposes  is  .i  mg. 
for  delicate  individuals,  and  i  mg.  for  those  who  are  fairly  robust;  if  no 
reaction  is  obtained  from  smaller  doses,  they  may  be  increased  to  5  or 
10  mg.  (b)  The  Calmette  method  consists  of  instilling  one  drop  of  a 
I  per  cent,  solution  of  tuberculin  into  the  eye;  if  conjunctivitis  follows 
the  test  is  positive.  The  method  is  not  without  danger,  particularly 
if  the  eye  is  not  normal,  (c)  The  Von  Pirquct  method  consists  in 
inoculating  the  tuberculin  into  the  skin  after  scarifying,  non- 
inoculated  scarification  being  used  as  control.  In  the  tuberculous  a 
papule  forms  at  the  site  of  vaccination,  (d)  The  Moro  test  is  per- 
formed by  rubbing  into  the  unbroken  skin  of  the  chest  or  abdomen, 
over  an  area  of  four  square  inches,  a  small  quantity  of  an  oint- 
ment consisting  of  5  c.c.  of  old  tuberculin  and  5  grammes  of  anhy- 
drous wool  fat.  In  a  day  or  two  a  number  of  small  papules  appear, 
if  the  patient  is  tuberculous. 

The  prognosis  is  good  if  the  lesion  is  localized  and  so  situated  as  to 
be  susceptible  of  eradication  by  surgical  means;  the  danger  of  recur- 
rence, however,  is  always  present.  In  general,  it  may  said  that  the 
prognosis  is  better  in  children  than  in  adults.  Undoubtedly  many 
cases  of  unsuspected  tuberculosis  recover  without  treatment,  but 
when  the  process  has  extended  sufificiently  to  be  recognizable,  par- 
ticularly in  medical  tuberculosis,  it  has  gained  such  a  foothold  that 
recovery  is  always  doubtful. 

The  treatment  is  local  and  constitutional.  The  most  important 
measure  in  the  local  treatment  is  rest.  Of  some  value  is  the  injection 
into  the  lesion  of  various  drugs,  among  which  may  be  mentioned 
carbolic  acid  (3  per  cent.),  tincture  of  iodin,  chlorid  of  zinc  (i-io), 
balsam  of  Peru,  oil  of  cloves  (i-io  in  olive  oil),  and  especially  iodo- 
form emulsion  (10  per  cent.).  It  is  probable  that  by  irritation  these 
medicaments  stimulate  the  fibroblasts,  and  thus  produce  firm  fibrous 
tissue  which  encapsulates  the  tubercles.  Bier  claims  good  results 
from  the  production  of  a  permanent  congestion,  by  a  rubber  tourni- 
quet placed  on  the  Hmb  above  the  tuberculous  area  (see  "Bier's 
Treatment,"  chap.  vi).  Radiotherapy  (X-rays,  radium),  photo- 
therapy (the  Finsen  light),  and  heliotherapy  (exposure  to  the  direct 
rays  of  the  sun)  have  proved  of  value  in  suitable  cases.  Heliother- 
apy is  best  administered  on  a  high  mountain  (helioalpintherapy) . 


212  MANUAL    OF    SURGERY 

According  to  Rollier  the  ultraviolet  rays  are  the  real  factor  in  healing 
tuberculosis;  these  cause  pigmentation,  and  the  pigment  acts  as  a 
sort  of  filter,  which  prevents  injury  to  the  skin  by  the  rays  of  short 
wave-length,  and  allows  the  others  to  penetrate,  causing  an  inflam- 
matory reaction  in  the  tissues  and  a  positive  chemotactic  leukocytosis. 
As  tuberculosis  is  always  a  general  disease,  Rollier  always  gives 
general  sun  baths,  beginning,  however,  gradually.  On  the  first  day 
the  feet  are  exposed  three  or  four  times  for  five  minutes,  later  the  legs, 
and  so  on,  until  finally  the  whole  body  may  be  exposed  for  six  or  eight 
hours.  Brilhant  results  have  been  obtained  with  this  form  of  treat- 
ment, but  it  takes  two  or  three  years,  and  in  many  cases  operation 
acts  just  as  well  within  a  much  shorter  time;  of  course  the  two  may 
be  combined.  The  operative  measures,  e.g.,  incision  and  curettage, 
excision,  amputation  of  a  diseased  limb,  and  removal  of  destroyed 
organs,  will  be  discussed  more  fully  on  the  pages  devoted  to  regional 
surgery. 

The  constitutional  treatment  consists  of  fresh  air,  food  (meats, 
milk,  eggs,  cream,  butter),  and  plenty  of  sunshine,  which  is  really  a 
form  of  heliotherapy.  Tonics  are  usually  indicated,  and  a  prolonged 
stay  at  the  seashore,  particularly  in  surgical  tuberculosis,  is  of  the 
greatest  value.  The  discharges  should  be  carefully  disinfected,  and 
susceptible  individuals  should  not  associate  with  those  in  whom  the 
disease  is  active.  Koch's  tuberculin  is  probably  of  some  value  in  the 
early  stages  of  tuberculosis,  but  is  rarely  employed  by  surgeons.  It, 
of  course,  is  impotent  against  the  pyogenic  organisms  which  are 
found  so  frequently  in  tuberculous  lesions,  and  it  should  never  be 
employed  alone,  but  always  in  conjunction  with  other  remedial 
measures.  The  dose  of  the  old  tuberculin  is  o.ooi  c.c,  injected  under 
the  skin  of  the  back;  if  the  patient  fails  to  react,  the  doses  are  grad- 
ually increased.  The  does  of  the  new  tuberculin  (T.R.)  is  0.002  mg. 
every  second  day,  increased  gradually  until  20  mg.  is  reached,  so 
that  a  rise  in  temperature  of  more  than  a  half  degree  is  avoided. 
The  treatment  may  then  be  discontinued  or  repeated  after  a  long 
interval.  The  old  tuberculin  (T.)  is  a  glycerin  extract  of  tubercle 
bacilli  from  which  the  bacteria  have  been  removed  by  filtering  through 
porcelain.  The  new  tuberculin  (T.R.)  is  made  by  triturating  dried 
bacilli  in  an  agate  mortar,  the  resulting  powder  being  put  into  dis- 
tilled water  and  the  solution  centrifugahzed.  The  upper  portion  of 
this  fluid  is  the  tubercuhn  O.  (Oberer),  which  has  the  same  properties 
as  the  old  tuberculin;  the  remaining  fluid,  tuberculin  R.  {R  tick  stand) , 
causes  a  general  but  not  a  local  reaction,  its  curative  effect  being  due 
to  the  production,  in  the  blood,  of  antibodies  to  the  tubercle  bacilH. 


GENERAL    CONDITIONS   AND    SPECIAL   INFECTIONS  213 

Koch's  latest  tuberculin,  B.  E.  {Bazillenemulsion) ,  is  an  emulsion 
of  ground  tubercle  bacilli  in  equal  parts  of  glycerin  and  water,  the 
dose  being  that  of  T.R.  Klebs  claims  good  results  from  the  use  of 
Hiherciilocidin,  or  antiphthisin,  which  is  tuberculin  from  which  the 
noxious  portions  have  been  separated.  Antituberculous  serum 
made  by  immunizing  animals  with  toxins  of  the  tubercle  bacillus 
have  been  employed,  notably  by  Maragliano  and  Alarmorek;  the 
value  of  these  serums  has  not  been  determined.  Among  the  drugs 
which  have  been  used  internally  in  tuberculosis  may  be  mentioned 
arsenic,  iodin,  creosote,  guaiacol,  cod-liver  oil,  lacto-phospha^.es, 
hypophosphites,  strychnin,  animal  and  vegetable  digestive  ferments, 
iron,  mineral  and  fruit  acids,  vegetable  tonics,  and  nucleins. 

Tuberculosis  of  special  structures  is  considered  under  various 
headings  throughout  the  book. 


CHAPTER  XIII 
TUMORS  AND  CYSTS 

A  tumor,  or  neoplasm,  is  a  mass  of  newly  formed  pathological 
tissue  which  tends  to  persist  or  grow  and  which  performs  no  physio- 
logical function.  Clinically,  however,  the  word  tumor  is  often 
applied  to  a  swelling  of  any  sort.  An  inflammatory  swelling  differs 
from  a  neoplasm  in  that  it  has  a  definite  cause  and  tends  to  subside;  a 
hypertrophy,  in  that  it  is  the  result  of  increased  work  and  persists 
only  so  long  as  the  demand  for  such  work  exists.  The  tissue  of  a 
neoplasm  has  its  prototype  in  the  human  body,  either  adult  or 
embryonic  {Midler's  law),  and  its  cells  invariably  originate  from 
preexisting  cells  of  the  body  (Virc/wic's  lau'). 

The  cause  of  neoplasms  is  not  known.  Cohnheim's  inclusion 
theory  is  that  an  excess  of  embryonic  cells  is  manufactured  during 
intrauterine  life,  and  that  those  which  are  not  used  in  the  construc- 
tion of  the  fetal  tissues  remain  in  the  body  in  a  latent  condition,  until 
some  irritation  stimulates  their  development.  The  influence  of 
heredity  is  probably  much  less  important  than  was  formerly  believed. 
Injury  and  irritation  are  undoutedly  important  factors  in  some  in- 
stances; thus  sarcoma  may  follow  a  single  injury,  carcinoma  some 
form  of  constant  irritation,  e.g.,  epithelioma  of  the  lip,  the  result  of 
smoking  a  short  stemmed,  clay  pipe.  ]\Iany  unsuccessful  attempts 
have  been  made  to  establish  the  infective  nature  of  tumors,  distinctly 
sarcoma  and  carcinoma.  Sarcoma  is  most  frequent  during  the  early 
half  of  life,  or  the  period  of  physiological  activity;  carcinoma,  during 
the  later  part  of  life,  or  the  period  of  physiological  decline. 

Clinically  tumors  may  be  divided  into  the  benign  and  the  malig- 
nant. 

A  benign,  innocent,  adult,  or  typical  tumor  may  be  multiple, 
strongly  resembles  in  structure  the  tissue  from  which  it  springs, 
grows  slowly,  is  encapsulated,  does  not  infiltrate  surrounding  tissues, 
is  usually  movable  (not  adherent) ,  seldom  ulcerates,  does  not  cause 
metastases  in  the  lymphatic  glands  or  in  distant  parts  of  the  body, 
does  not  recur  after  thorough  removal,  and  is  serious  only  when  so 
situated  as  to  press  on  important  structures. 

A  malignant,  atypical,  or  embryonic  tumor  is  usually  single,  is 
composed  of  cells  resembhng  those  found  in  the  embryo,  grows  rapid- 

214 


TUMORS    AND    CYSTS  215 

ly,  is  not  (.'111^11)8111^110(1,  infiltrates  the  surroundin*^  tissues  (fixed), 
and  often  j)r()<i;resses  to  ulceration,  causes  metastases  in  adjacent 
lymph  frlands  or  in  distant  parts  of  the  body,  frequently  recurs  after 
excision,  is  always  serious,  and  ultimately  destroys  life  no  matter 
what  its  position. 

Tumors  may  be  classified  according  to  their  origin  as  follows: 

(I)  Epithelial  tumors  (derived  from  the  epiblast  or  the  hypo- 
blast). 

(A)  Bcnii^ii,    or   innocent    tumors    (those    composed    of  adult 
epithelial  tissue). 

(i)  Papilloma  or  warty  growth. 
(2)  Adenoma,  or  glandular  tumor. 

(B)  Malignant   tumors,    or   carcinomata    (those   composed    of 
embryonic  epithelial  tissue). 

(i)  Epithelioma. 
(2)   Glandular  carcinoma. 
(chorioei)ithelioma) . 

(II)  Connective  tissue  tumors  (those  derived  from  mesoblastic 

tissue.) 
(A)  Benign  (those  conforming  to  types  of  adult  mesoblastic 
structures). 
(i)  Fibroma  (fibrous  tumor). 

(2)  Lipoma  (fatty  tumor). 

(3)  Chondroma  (cartilaginous  tumor). 

(4)  Osteoma  (bony  tumor). 

(5)  Myxoma  (mucous  tumor). 

(6)  Myoma  (muscle  tumor). 

(7)  Hemangioma  (tumor  composed  of  blood  vessels). 

(8)  Lymphangioma  (lymphatic  vessel  tumor). 

(9)  Neuroma  (nerve  tumor). 

(10)  Odontoma  (tooth  tumor). 

(11)  GHoma  (tumor  of  neuroglia). 

(B)  Malignant   tumors,   or  sarcomata   (those  conforming  to  em- 
bryonic mesoblastic  tissue). 
(Endothehoma). 
(Hypernephroma) . 

(III)  Mixed  tumors,  or  teratomata  (those  composed  of  epiblastic, 

mesoblastic,  and  hypoblastic  structures). 

I-.  Epithelial  tumors,  or  those  derived  from  the  epiblast  or  the 
hypoblast. 

(A)  Innocent  Epithelial  Tumors.— (i)  Papillomata,  or  warts,  are 
derived  from  cutaneous  or  mucous  papillse,  which  they  closely  resem- 


2l6  MANUAL    OF    SURGERY 

ble  in  structure.  They  are  essentially  benign,  but  may  become  car- 
cinomatous during  the  later  half  of  life.  They  occur  at  any  age,  may 
be  single  or  multiple,  are  often  due  to  irritation  (e.g.,  veneral  uart 
from  acrid  discharges,  warts  of  the  hands  from  uncleanliness) ,  and 
sometimes  disappear  without  treatment.  Skin  warts  are  usually 
dark  in  color  owing  to  the  deposition  of  pigment.  Condylomata  and 
mucous  patches  are  papillomatous  in  nature.  Villous  warts  consist 
of  branching  tufts  resembling  chorionic  villi,  are  most  frequent  in  the 
bladder,  and  are  very  vascular  and  covered  by  a  thin  epithehal  layer 
which  is  easily  broken,  causing  frequent  and  occasionally  fatal  hem- 
orrhages. Villous  warts  are  found  also  in  the  pelvis  of  the  kidney, 
and  in  cysts,  more  particularly  those  arising  in  connection  with 
glands,  such  as  the  breast,  thyroid,  and  ovary. 

The  treatment  is  removal  by  caustics,  carbon  dioxid  snow,  fulgura- 
tion.  radiotherapy,  knife,  scissors,  or  special  instruments,  according 
to  their  location. 

(2)  Adenomata  spring  from  glandular  tissue,  which  they  closely 
resemble  in  structure.  They  grow  slowly,  are  benign,  occasionally 
follow  an  injury,  and  are  encapsulated.  They  may  undergo  fatty, 
cystic  (cystadenoma) ,  mucoid  iadenomyxoma)  or  carcinomatous 
degeneration  (adenocarcinoma).  Sarcomatous  degeneration  of  the 
fibrous  stroma  produces  an  adenosarcoma.  Adenomata  may  occur 
in  any  gland,  but  are  most  frequently  found  in  the  breast,  prostate, 
thyroid,  parotid,  ovary,  testis,  and  in  the  lachrymal,  cutaneous,  and 
mucous  glands.  There  are  two  varieties,  the  acinous,  or  racemose 
adenoma,  which  consists  of  communicating  sacs,  or  acini,  lined  with 
epithelium,  and  the  tubular  adenoma  ffound  principally  in  the  intes- 
tine, where  there  are  numerous  tubular  glandsj.  which  consists  of 
tubuk's  lined  with  cylindrical  epithelium;  the  latter  are  peculiarly 
liable  to  become  carcinomatous  (adeno-carcinoma).  When  the 
connective  tissue  is  excessive  in  amount,  the  tumor  is  known  as  a 
fibroadenoma. 

The  treatment  is  excision. 

(B)  Carcinomata,  or  cancers,  consist  of  masses,  or  nests,  of 
epithelial  cells  in  the  form  of  alveoli  and  surrounded  by  fibrous  tissue, 
which  communicate  with  one  another  and  with  the  lymphatics,  thus 
accounting  for  the  frequency  of  secondary  growths  in  the  lymphatic 
glands.  The  epithelial  cells  are  loosely  thrown  together  and  are  not 
separated  by  an  intercellular  matrix.  The  blood  vessels  run  in  the 
fibrous  stroma,  have  distinct  walls,  and  do  not  communicate  with 
the  alveoli.  The  growth  spreads  by  infiltrating  the  surrounding 
tissues  in  the  form  of  processes  (roots)  and  is  never  encapsulated.     It 


TUMORS    AND    CYSTS 


217 


is  at  first  local  and  usually  single,  hence  curable  by  excision;  later 
the  lymphatic  glands  become  involved  and  finally  metastases  occur 
in  distant  parts  of  the  body  {carcinomatosis).  On  reaching  the 
surface  carcinoma  ulcerates,  giving  rise  to  a  foul,  purulent,  and  often 
bloody  discharge  which  rapidly  exhausts  the  patient,  causing  ema- 
ciation, a  sallow  color  of  the  skin,  and  an  anxious  expression  of  the 
face  {cancerous  cachexia).  In  carcinoma  of  the  viscera,  particularly 
of  the  digestive  tract,  cachexia  is  earlier  in  onset  and  more  rapid  in 
progress,  because  of  the  interference  with  nutrition.  It  may  be  that 
the  cachexia  is  in  part  due  to  the  absorption  of  toxins  from  the  malig- 
nant growth,  fever,  however,  seldom  occurs  unless  there  is  ulceration. 
Carcinoma  is  most  frequent  after  the  thirty-fifth  year.  Of  the 
secondary  changes  that  may  occur  fatty  degeneration  is  the  most 
important,  indeed  it  may  be  said  to  be  almost  constant  in  the  later 
stages  of  large  cancers.  Cutaneous  epithelioma  may  undergo  a 
horny  transformation.  Mucoid  and  colloid  degeneration  may  occur, 
and  occasionally  pigmentation  cyst  formation,  or  calcification. 
Cancer  of  the  penis  in  rare  instances  may  be  due  to  cancer  of  the 
cervix  uteri,  and  under  favorable  circumstances  a  portion  of  the 
growth  may  be  grafted  upon  another  portion  of  the  patient's  body, 
(see  "Malignant  Disease  of  the  Peritoneum"),  but  the  disease  is  by 
no  means  contagious  in  the  ordinary  sense  of  the  word.  Carcinoma 
is  most  frequent,  in  the  order  named,  in  the  stomach,  the  uterus, 
the  esophagus,  the  breast,  the  rectum. 

(i)  EpitheUoma  may  be  squamous-  or  cylindrical-celled. 

Squamous  epithelioma  may  occur  on  any  portion  of  the  skin  or 
mucous  membrane,  but  most  frequently  arises  where  skin  and  mu- 
cous membrane  meet,  or  where  two  varieties  of  epithelium  come  to- 
gether. The  favorite  sites  are  the  nose,  lower  lip,  penis,  scrotum, 
vulva,  anus,  tongue,  palate,  gums,  tonsils,  larynx,  pharynx,  esopha- 
gus, bladder,  and  os  uteri.  The  epithehal  cells  grow  from  the 
surface  into  the  lymph  spaces  in  the  form  of  columns,  and  are  prone 
to  arrange  themselves  in  globular  masses  called  pearls.  The  disease 
begins  as  a  nodule  or  fissure  which  quickly  ulcerates;  in  fact  the  ulcera- 
tion may  progress  more  rapidly  than  the  epithelial  proliferation,  so  that 
in  a  strict  etymological  sense,  the  term  tumor  cannot  be  applied. 
With  the  exception  of  rodent  ulcer,  which  will  be  described  under 
diseases  of  the  skin,  epitheHoma  presents  all  the  features  of  malig- 
nancy mentioned  above.  The  ulcer  is  irregular,  with  a  non-granulat- 
ing base,  hard,  everted  edges,  and  an  irritating  discharge,  which,  on 
the  skin,  may  form  a  scab.  On  section  the  surface  is  firm  and  white. 
It  contains  but  little  fluid,  but  on  pressure  may  exude  fine,  white. 


2l8  MANUAL    OF    SURGERY 

worm-like  masses.  Epithelioma  is  less  malignant  than  glandular 
carcinoma,  the  disease  sometimes  lasting  for  years.  The  most 
marked  exception  to  this  statement  is  epithelioma  of  the  tongue, 
which  may  cause  death  in  a  few  months.  Epithelioma  arising  from 
an  old  ulcer  or  a  cicatrix  is  called  Marjolin's  ulcer.  Lymphatic 
glands  are  often  not  involved  for  a  number  of  months,  and  metastatic 
growths  in  distant  portions  of  the  body  are  not  common. 

Cylindrical-  or  columnar-celled  epithelioma  (malignant  adenoma) 
might  properly  be  classified  with  glandular  carcinoma;  it  arises  from 
cylindrical  epithelium  on  the  surface  or  in  the  glands  of  the  mucous 
membranes,  being  most  frequent  in  the  uterus  and  intestinal  tract. 
The  growth  is  less  common  than  squamous  or  glandular  cancer  but 
occurs  much  earlier  in  life,  a  fact  which  is  particularly  true  of  the 
rectum.  It  consists  of  Httle  cavities  or  tubules  lined  by  a  number  of 
layers  of  epithehum  without  a  basement  membrane. 

(2)  Glandular,  or  acinous  carcinoma,  springs  from  glandular 
epithelium,  and  consists  of  acini,  or  alveoH,  of  connective  tissue  filled 
with  epithelial  cells.  It  is  usually  nodular,  the  degree  of  hardness 
varying  with  the  amount  of  fibrous  tissue.  A  simple  carcinoma  is 
one  in  which  the  epithelium  and  connective  tissue  exist  in  about  the 
same  proportion  as  in  the  normal  gland.  In  a  scirrhus,  or  hard 
cancer,  there  is  an  excess  of  fibrous  tissue.  On  section  the  surface 
becomes  concave  owing  to  the  contraction  of  the  fibrous  tissue,  is 
white  and  glistening,  creaks  under  the  knife,  and  exudes  a  milky 
fluid  containing  degenerated  epithelium  and  oil  globules.  A  scirrhus 
is  a  dense  nodular  growth  firmly  imbedded  in  the  tissues,  causing, 
when  just  beneath  the  skin,  a  puckering  or  dimpling  owing  to  the 
contraction  of  the  fibrous  tissue.  In  some  cases  this  contraction  is  so 
marked  that  the  tumor  decreases  in  size  (atrophic,  or  withering 
scirrhus),  without,  however,  markedly  interfering  with  general 
dissemination  of  the  growth.  Scirrhus  is  most  frequent  in  the  breast 
and  alimentary  canal,  particularly  the  pylorus.  Encephaloid,  medul- 
lary, or  soft  cancer  contains  an  excess  of  epithehal  cells;  consequently 
it  is  a  soft  nodular  mass  which  grows  very  rapidly  (hence  the  term 
acute  cancer),  quickly  involves  the  lymphatic  glands,  and  is  speedily 
fatal;  after  ulceration  it  presents  a  fungating,  bleeding  surface  {fungus 
hematodes).  On  section  it  looks  not  unhke  brain  tissue  into  which 
hemorrhages  have  occurred.  The  central  portion  of  the  growth  may 
be  semi-fluid,  or  in  some  instances  actual  cysts  may  be  found.  It  is 
much  less  common  than  scirrhus,  and  is  most  frequent  in  the  breast 
and  testicle.  Colloid,  or  gelatinous  cancer,  is  the  result  of  a  colloid  or 
myxomatous  degeneration  of  any  glandular  carcinoma.     It  is  most 


TUMORS    AND    CYSTS  2IQ 

frequent  in  the  abdominal  cavity,  and  is  occasionally  found  in  the 
breast. 

Cliorio-epilhcHoma  {dcciduoma  malignum,  syncylioma  malignum) 
may  be  placed  provisionally  among  the  carcinomata  because  it  is 
epithelial  in  origin  and  malignant  in  nature.  The  tumor  arises 
from  the  chorionic  epithelium  following  pregnancy,  and  resembles  in 
appearance  the  placental  tissue,  blotched  with  blood.  In  nearly 
half  the  cases  there  has  been  a  hydatidiform  mole.  It  quickly  gives 
rise  to  secondary  growths  in  distant  portions  of  the  body  by  breaking 
into  the  blood  vessels. 

The  treatment  of  carcinoma  is  early  and  wide  excision,  together 
with  the  lymphatic  glands  into  which  the  diseased  area  drains;  in  one 
mass  if  possible,  in  order  not  to  sever  the  lymphatic  vessels,  as  such 
an  accident  may  sow  the  wound  with  cancer  cells  and  cause  recurrence. 
If  operation  be  early  and  thorough,  cure  may  be  expected,  but  as 
most  cases  come  to  operation  late,  complete  eradication  is  often  not 
attained  and  recurrence  follows.  Even  in  cases  in  which  cure  cannot 
be  expected,  removal  of  the  growth  is  often  indicated  to  relieve  pain 
or  to  take  away  a  foul-smelling,  bleeding,  ulcerating  mass.  Super- 
licial  epithehoma  of  the  skin,  notably  rodent  ulcer,  may  be  cured  by 
the  X-rays  or  radium,  and  in  such  cases  only  should  these  agents  be 
used  alone  when  the  growth  is  operable;  after  excision,  however,  it 
is  often  advisable  to  employ  radiotherapy,  with  the  hope  of  prevent- 
ing or  retarding  recurrence. 

In  the  treatment  of  inoperable  carcinoma  it  is  often  possible  only  to 
relieve  pain  by  such  drugs  as  morphin  and  to  disinfect  ulcerating 
surfaces.  In  some  cases  removal  of  large  portions  of  the  growth  by 
excision  or  curettage,  followed  by  cauterization  with  zinc  chlorid  or 
the  actual  cautery,  or  by  fulguration,  may  be  indicated  for  pain, 
hemorrhage,  or  fetor.  Fulguration  (de  Keating-Hart),  which  "con- 
sist in  projecting  on  the  operative  field  a  shower  of  sparks  supplied  by 
an  alternating  current  of  high  frequency  and  high  tension, "  causes  a 
superficial  necrosis  and  is  probably  no  better  than  cauterization;  it 
requires  chloroformization,  as  either  is  dangerous  because  of  the 
sparks.  In  other  cases  pain  may  be  abolished  by  severing  the  nerve 
which  supplies  the  affected  region,  and  occasionally  life  may  be 
prolonged  by  ligation  of  the  principal  arteries  nourishing  the  part. 
In  inoperable  growths  about  the  face  and  jaws  Dawbarn  excises 
both  external  carotids.  Among  palliative  operations  may  be  men- 
tioned gastrostomy  for  cancer  of  the  esophagus,  gastroenterostomy 
for  cancer  of  the  pylorus,  inguinal  colostomy  for  cancer  of  the  rectum, 
and  tracheotomy  for  cancer  of  the  larynx.     In  inoperable  carci- 


2  20  MANUAL    OF    SURGERY 

noma  of  the  breast  Beatson  removes  the  ovaries,  with  temporary- 
benefit  in  some  cases.  The  various  cancer  serums  have  proved  of 
value  in  the  hands  of  their  inventors  only.  Coley's  fluid  may  be 
tried  in  inoperable  cancer,  but  it  finds  its  chief  indication  in  sarcoma 
(q.v.).  The  injection  of  drugs,  such  as  pyoktanin,  thiosinamin, 
methyl  violet,  etc.,  is  of  such  little  value  that  their  use  may  be 
ignored.  Radiotherapy  is  often  of  decided  benefit  in  mitigating 
pain,  lessening  discharge,  and  diminishing  fetor. 

n.  Mesoblastic,  or  connective -tissue  tumors,  are  those  derived 
from  mesoblastic  tissue. 


Fig.   79. — The  upper  rounded  growth  is  a  hard  fibroma,  the  lower  lobulated  growths 

are  soft  fibromata. 

(A)  Innocent  connective -tissue  tumors,  (i)  Fibromata  are 
tumors  composed  of  fibrous  tissue.  The  growth  may  be  liard  or 
soft  (Fig.  79)  according  to  the  density  of  the  fibrous  tissue  and  the 
amount  of  liquid  which  it  contains.  Fibromata  may  arise  from 
fibrous  tissue  in  any  part  of  the  body,  but  are  most  commonly  found 
in  connection  with  the  periosteum  {e.g. ,  fibrous  epulis  of  the  jaw),  skin 
and  subcutaneous  tissues,  submucous  tissues  {fibrous  polypi  of  the 
rectum  and  nasopharynx),  nerve  sheaths  {false  neuroma),  tendons, 
uterus,  ovaries,  and  kidneys.  Keloid  is  a  hard  fibroma  of  the  skin 
developing  spontaneously  {true  keloid)  or  attacking  scar  tissue  {cica- 
tricial, or  false  keloid).  Molluscum  fibrosum  (see  Neurofibromatosis, 
chap,  xvii)  is  a  soft  fibroma,  which  may  occur  as  numerous  small 


TUMORS    AND    CYSTS 


221 


nodules,  or  as  h  diffuse  form  in  which  the  skin  hangs  in  pendulous  folds 
{pac/ivdcrmatocclc).  Fibromata  are  usually  rounded,  lobulated,  en- 
capsulated, and  of  slow  growth..  With  the  exception  of  keloid  (see 
chapter  on  skin)  and  fibromata  which  contain  sarcomatous  elements, 
recurrence  does  not  take  place  after  removal,  which,  again  excepting 
keloid,  is  in  general  terms  the  treatment.  Fibroma  is  often  asso- 
ciated with  other  forms  of  tumor  growth,  giving  rise  to  compound 


Fig.  8o. — Huge  fibrolipoma,  springing  from  the  periosteum  of  the  clavicle,  and  under- 
going necrosis. 

terms,  such  as  fibrolipoma  (Fig.  80) ,  fibromyxoma,  fibromyoma,  and 
fibrosarcoma,  while  cystic,  colloid,  and  calcareous  degenerations  may 
occur. 

(2)  Lipomata  (Fig.  81)  are  composed  of  fat  resembl  ng  that  of  the 
epiploic  appendages.  A  lipoma  is  soft,  lobulated,  and  elastic,  often 
presenting  pseudo-fluctuation;  it  is  dehcately  encapsulated,  and  when 
situated  in  the  subcutaneous  tissues  is  ovoid  in  shape,  and  causes  a 


222 


MANUAL    OF    SURGERY 


dimpling  of  the  skin  when  moved,  owing  to  the  numerous  fibrous 
strands  which  pass  from  the  capsule  to  the  skin.  A  fatty  tumor  may 
contain  an  excess  of  fibrous  tissue  (fibrolipoma),  or  a  large  number  of 
dilated  blood  vessels  (nevolipoma).  They  grow  slowly,  sometimes  reach 
a  very  large  size,  are  commonly  single  but  may  be  multiple  and  (Fig.  83) 
are  most  frequent  in  mid-life  but  occur  also  as  congenital  growths. 
Among  the  secondary  changes  are  calcification,  ossification,  ulcera- 
tion, inflammation,  mucoid  softening,  and  cystic  degeneration. 
Lipomata  occasionally  change  their  location  as  the  result  of  gravity, 
and   sometimes   become  pedunculated.     Subcutaneous  lipomata  are 

most  common  on  the  back  and 
about  the  shoulders.  Submucous 
lipomata  are  rare.  Subsynovial 
lipomata  may  project  into  a  joint 
in  the  form  of  a  villous  growth 
(lipomata  arborescens)  and  be  asso- 
ciated with  an  increase  in  the  joint 
fluid  {synovitis  lipomatosis).  Sub- 
serous lipomata  of  the  abdomen 
may  form  large  retro-peritoneal 
tumors,  or,  when  occurring  anteri- 
orly, may  insinuate  themselves 
through  congenital  openings  in  the 
abdominal  wall  or  even  make  for 
themselves  an  opening  (e.g.,  epigas- 
tric hernia)  and  draw  the  perito- 
neum after  them,  thus  producing 
a  hernia.  Subfacial  lipomata  of 
the  palm  or  sole  may  be  mistaken 
for  a  compound  ganglion.  Fatty 
tumors  beneath  the  occipito-front- 
alis  are  often  connected  with  the 
periosteum,  and  are  most  frequent  on  the  forehead.  Intermuscular 
lipomata,  which  often  spring  from  the  periosteum,  are  frequently 
mistaken  for  a  chronic  abscess  or  a  sarcoma.  Diffuse  lipomata  (Fig. 
82)  is  a  localized  obesity,  frequently  occurring  in  the  cervical  region 
as  double  chin  or  double  neck.  The  fat  in  this  variety  is  granular 
and  resembles  omentum.  Xanthoma  is  classified  as  a  fibroma  by 
some  authors.  It  is  composed  of  connective-tissue  cells  infiltrated 
with  fat,  and  is  a  small,  flat  (X.  planum),  or  elevated  (X.  tuberosum) 
yellowish  growth,  seen  most  frequently  on  the  eyelids.  It  may  be 
single  or  multiple,  and  is  sometimes  associated  with  disease  of  the 


Fig.   81. — Large  lipoma  of  arm. 


TUMORS    AND    CYSTS 


223 


liver  or  diubclcs.     Large  xunLhoniata  are  very  rare,  occur  most  (jfLen 
on  the  knee  and  the  heel,  and  contain  sarcomatous  elements. 

The  treatment  of  lipoma  is  excision,  which,  in  the  ordinary, 
circumscribed  subcutaneous  variety,  is  readily  done  by  incising  the 
capsule  and  enucleating  the  growth  with  the  linger;  adhesions, 
however,  may  make  this  difficult.  In  the  diffuse  variety  dietetic 
measures  may  be  tried,  and  liquor  potassae,  m.  10  t.d.,  for  a  prolonged 
period  has  been  advised.      These  measures,  however,  will  be  found  of 


Fig.   82. — Diffuse  lipoma  of  the  neck  and  chest. 

little  use,  and  complete  excision,  which  is  often  troublesome,  offers 
the  only  chance  of  cure. 

(3)  Chondroma  is  a  tumor  composed  of  cartilage,  often  occurs  at 
puberty,  is  found  most  frequently  growing  from  bones,  particu- 
larly those  of  the  hand,  foot,  femur,  and  pelvis,  and  is  occasionally 
seen  in  the  salivary  glands,  breasts,  ovaries,  testicles,  tendons,  and 
muscles.  The  secondary  changes  which  may  take  place  are  fatty, 
mucoid,  calcareous,  and  cystic  degenerations,  while  ossification 
is  not  infrequent,  particularly  in  those  which  spring  from  the  epiphy- 


2  24  MANUAL    OF    SURGERY 

seal  lines  of  long  bones.     In  the  parotid  and  testicle  mixed  tumors 
may  occur,  i.e.,   the  growth  may  be  associated  with  myxoma  or 


Fig.  83. — Multiple  subcutaneous  lipomata.      (Pennsylvania  Hospital.) 

sarcoma,  or  both.  EccJiondroma^  or  ecchondrosis,  occurs  as  a  spur  or 
rounded  out- growth  from  bones  or  cartilages.  Enchondroma  spnngs 
from  the  inner  surface  of  bone,  projecting  into  the  marrow  cavity. 


TUMORS    AND    CYSTS  225 

All  forms  are  hard  and  inelastic,  grow  slowly,  and  may  be  single, 
symmetrical,  or  multiple.  The  treatment  is  removal.  In  mixed 
tumors  recurrence  may  be  expected. 

(4)  Osteoma  (bony  tumor)  is  really  an  ossified  chrondroma, 
hence  subject  to  the  general  statements  made  in  the  preceding 
paragraph.  It  usually  develops  where  bone  and  cartilage  meet, 
either  projecting  from  the  exterior  of  the  bone  (exostosis)  or  from  the 
the  interior  {endostosis) ;  and  is  composed  of  compact  bone  [osteoma 
durum),  cancellous  bone  {osteoma  spongiosum) ,  or  extremely  dense 
bone  in  which  no  blood  vessels  or  Haversian  canals  are  found  (ebur- 
nated  osteoma).  Osteoma  rarely  reaches  a  large  size,  and  usually 
ceases  growing  when  adult  Hfe  is  reached.  Bursae  not  infrequently 
develop  over  an  exostosis  as  the  result  of  pressure.  A  subungual 
exostosis,  most  frequently  seen  beneath  the  nail  of  the  great  toe, 
is  exceedingly  painful  and  necessitates  removal  of  the  nail  in  order 
to  expose  and  remove  the  growth.  Diffuse  hypertrophy  of  the  bones 
of  the  face  (leontiasis  ossea)' and  the  bony  growths  found  in  muscles 
and  tendons  as  the  result  of  irritation  {myositis  ossificans)  are 
osteomatous  in  nature.  The  treatment  is  removal,  except  in  cases 
in  which  a  formidable  operation  would  be  necessary  for  a  growth 
which  is  producing  but  httle  annoyance. 

(5)  Myxoma  is  composed  of  mucoid  tissue,  resembUng  the 
Wharton's  jelly  of  the  umbilical  cord  or  the  vitreous  humor  of  the  eye. 
It  is  most  common  in  the  subcutaneous,  subserous,  and  submucous 
tissues,  and  in  the  perineurium,  and  is  a  soft  gelatinous  growth 
which  may  be  sessile  or  pedunculated,  in  the  latter  instance  forming 
a  polyp.  Hydatid  moles  are  due  to  myxomatous  degeneration  of 
chorionic  villi.  Myxoma  is  often  associated  with  other  forms  of 
tumor,  and  not  infrequently  recurs  after  removal,  owing  to  the 
presence  of  sarcomatous  elements;  for  this  reason  the  treatment  should 
be  early   and  thorough  extirpation. 

(6)  Myoma  occurs  as  leiomyoma  (smooth  non-striated  muscle 
cells)  or  as  rhabdomyoma  (striated  muscle  elements).  Leiomyoma 
is  most  common  in  the  uterus  (where,  owing  to  the  quantity  of 
fibrous  tissue  present,  it  is  called  fibromyoma),  gastrointestinal 
tract,  and  prostate.  It  is  encapsulated,  firm  in  consistency,  reddish 
on  section,  and  frequently  stratified  or  concentric  in  arrangement. 
Among  the  secondary  changes  which  may  occur  are  inflammation, 
ulceration  or  necrosis,  and  cystic,  fatty,  myxomatous,  sarcomatous, 
or  calcareous  degeneration.  It  may  be  excessively  supplied  with 
large  blood  vessels  (myoma  cavernosum).  Rhabdomyoma  is,  as  a 
rule,  chiefly  sarcomatous,  the  proportion  of  striped  muscular  fiber 

15 


2  26  MANUAL    OF    SURGERY 

being  small;  it  is  rare,  mostly  congenital,  and  is  found  in  the  kidney, 
ovary,  and  testicle.     The  treatment  is  excision. 

(7)  Hemangiomata,  or  tumors  composed  of  blood  vessels, 
occur  in  three  forms. 

(a)  Simple  nevus,  or  angioma  telangiectaticum,  consists  of  dilated 
capillaries,  arterioles,  and  venules.  When  the  arterioles  are  princi- 
pally involved,  the  growth  is  bright  red  {nevus  flammeus,  or  straw- 
berry mark) ;  when  the  venules  predominate,  the  color  is  dark 
red  (nevus  venosus,  or  port  wine  mark).  These  tumors  are  slightly 
elevated,  usually  located  on  the  face  or  neck,  and  are  commonl}^ 
congenital,  hence  the  terms  birth  mark,  mother's  mark.  A  nevus 
may  remain  unchanged,  disappear,  or  rapidly  increase  in  size. 
Violent  hemorrhage  results  from  injury  or  ulceration. 

(b)  Cavernous  angioma  is  composed  of  irregular  sinuses,  and 
resembles  in  structure  the  corpus  cavernosum,  indeed  may,  like  it, 
be  erectile.  The  arteries  empty  immediately  into  the  venous  spaces 
without  the  intervention  of  capillaries.  Such  growths  occur  in  the 
skin  (nevus  prominens),  subcutaneous  tissue,  and  in  the  viscera, 
particularly  the  liver,  but  are  seldom  congenital.  A  simple  angioma 
may  become  cavernous  in  type.  The  term  telangiectatic  is  applied 
to  various  tumors  which  contain  an  excess  of  blood  vessels,  cavern- 
ous to  those  in  which  these  blood  vessels  are  of  very  large  cahbre; 
these  changes  are  most  frequent  in  sarcomata,  fibromata,  and  carcino- 
mata.  An  angioma  occasionally  becomes  sarcomatous.  A  cavern- 
ous angioma  may  be  emptied  on  pressure,  and  sometimes  there  are 
pulsation  and  bruit.  Spontaneous  cure  from  inflammation  is 
possible,  the  process  leading  to  thrombosis  with  subsequent  organi- 
zation of  the  clot. 

(c)  Plexiform  angioma  {racemose  aneurysm,  aneurysm  by  anas- 
tomosis, cirsoid  aneurysm)  is  really  nor  a  tumor  but  a  varicose 
condition  of  arteries,  which  become  elongated,  thickened,  and  con- 
voluted. Arterial  varix  is  a  varicosity  of  one  artery  only  (see  chapter 
on  "Vascular  System"). 

The  treatment  of  hemangiomata  is  excision  whenever  possible. 
Elliptical  incisions  are  made  around  the  growth  in  the  healthy 
tissues,  and  the  resulting  wound  sutured.  Ligation  by  placing  a  pin 
through  the  base  of  the  nevus  and  winding  a  hgature  beneath,  or  by 
tying  the  base  of  the  nevus  in  sections,  is  much  less  preferable  than 
excision.  Cauterization  with  fuming  nitric  acid,  ethylate  of  soda,  or 
the  actual  cautery,  may  be  employed  if  the  growth  is  minute  and 
superficial.  The  injection  of  coagulating  fluids,  such  as  Monsel's 
solution,  carbohc  acid,  and  boihng  water  may  produce  emboUsm, 


TUMORS    AND    CYSTS  227 

and  possesses  no  advantages  over  electrolysis,  which  is  useful  in  cases 
in  which,  owing  to  the  extent  of  the  growth,  excision  is  impossible, 
and  in  cases  in  which  a  minimum  of  scarring  is  desired.  One  or 
more  needles  connected  with  the  positive  pole  of  a  battery  are  insert- 
ed into  the  growth,  while  a  large  electrode,  connected  with  the  negative 
pole  is  placed  on  some  indifferent  part  of  the  body;  the  needles 
should  be  insulated  to  near  the  point  in  order  to  protect  the  skin. 
From  25  to  200  milliamperes  may  be  used  for  from  ten  to  fifteen 
minutes;  an  .  anesthetic  may  be  required.  The  mass  becomes 
firm  owing  to  the  coagulation  of  blood,  and  the  hardness  gradually 
disappears  with  the  absorption  of  the  thrombus.  The  number  of 
applications  will  vary  with  the  size  of  the  growth,  the  interval 
between  the  seances  being  about  ten  days.  Payr  recommends, 
particularly  in  inoperable  angiomata,  the  introduction  of  slivers  of 
magnesium  in  all  directions  through  a  small  wound;  the  metal  is 
absorbed  and  induces  coagulation. 
Pusey  freezes  small  nevi  with  carbon 
dioxide  snow,  which  is  collected  in  a 
piece  of  chamois  skin  from  a  metal 
cylinder  and  moulded  to  the  shape  of 
the  lesion,  to  which  it  is  applied  with 
forceps  for  from  ten  to  thirty  seconds. 
After  the  scab  which  forms  drops  off 

little  or  no  scarring  follows,   unless  the        Fig    84  —Congenital  cavernous 
,.  .         ,  ,  ,  ]         D    J-  hmphangioma. 

treezmg  has  been  prolonged.     Radio- 
therapy has  given  satisfactory  results  in  some  superficial  growths. 

(8)  Lymphangioma  is  a  tumor  made  up  of  dilated  lymph  vessels 
(lymphangiectasis),  or  more  frequently  lymph  spaces  {cavernous 
lymphangioma — Fig.  84).  Lymphangiomata  are  very  prone  to 
inflammation  and  this  sometimes  results  in  their  disappearance. 
The  condition  may  be  seen  in  the  tongue  {macroglossia),  in  the  lip 
(macrocheilia) ,  or  in  the  skin  {nevus  lymphaticus).  Congenital  cystic 
hygroma  is  due  to  dilatation  of  lymph  spaces.  Lymphadenoma,  or 
lymphoma,  and  lymph  edema  and  varicosities  due  to  obstruction  of 
lymph  vessels,  are  described  with  the  diseases  of  the  lymphatic 
system.     The  treatment  of  lymphangioma  is  that  of  hemangioma. 

(9)  Neuroma  (see  chap.  xvii). 

(10)  Odontoma  is  a  tumor  composed  of  dental  tissue.  Sutton 
describes  seven  varieties:  i.  Epithelial  odofitoma  (fibrocystic  disease 
of  the  jaw)  springs  from  the  enamel  organ  and  forms  an  encapsulated 
cystic  tumor,  usually  in  the  lower  jaw.  The  growth  may  be  very 
large  and  has  been  mistaken  for  sarcoma.     This  variety,  although 


2  28  MANUAL    OF    SURGERY 

of  epiblastic  origin,  is  mentioned  here  so  as  not  to  separate  it  from 
the  other  odontomata,  which  arise  from  mesoblastic  structures, 
2.  Follicular  odontoma  (dentigerous  cyst)  is  a  cavity  containing 
an  unerupted  permanent  tooth.  3.  Fibrous  odontoma  is  a  thickening 
of  the  fibrous  capsule  of  the  tooth  sac,  which  may  become  so  great  as 
to  prevent  eruption  of  the  tooth;  it  is  said  to  occur  in  rickety  children. 
4.  Cementoma  encases  the  tooth  in  cement;  it  is  seen  in  ruminants 
but  rarely  in  man.  5.  Radicular  odontoma  arises  from  the  tooth 
papilla  after  eruption  of  the  crown,  and  consists  of  cementum  and 
dentine.  6.  Compound  follicidar  odontoma  is  a  fibrous  tumor  con- 
taining numerous  denticles  which  erupt  at  intervals.  7.  Composite 
odontoma  is  composed  of  a  mixture  of  enamel,  dentine,  and  cemen- 
tum. The  treatment  of  dentigerous  cyst  is  removal  of  the  anterior 
wall,  with  cauterization  and  packing  of  the  cavity.  On  other  forms  of 
odontoma  excision  may  be  indicated. 

(11)  Glioma  is  a  tumor  springing  from  the  neurogha;  it  consists 
of  round  cells,  from  which  fine  processes  extend,  forming  an  inter- 
lacing reticulum.  Gliosis  refers  to  a  diffuse  gliomatous  change, 
such  as  is  seen  in  the  spinal  cord  in  syringomyelia.  A  glioma  may 
become  nfiltrated  with  blood,  develop  cysts,  or  undergo  a  sarcoma- 
tous change,  indeed  some  authors  believe  it  to  be  always  sarcoma- 
tous, hence  the  term  glio sarcoma.  Glioma  of  the  eyeball,  a  growth 
which  springs  from  the  retina  in  children,  is  always  a  round-celled 
sarcoma.     The  treatment  of  glioma  in  suitable  cases  is  excision. 

(B)  Sarcomata,  or  malignant  connective  tissue  tumors,  are  com- 
posed of  embryonic  or  immature  tissues  of  mesoblastic  origin.  They 
are  often  smooth,  regular  in  outhne,  and  enclosed  by  a  pseudocapsule, 
but  may  be  infiltrating  in  character.  They  resemble  flesh  in  con- 
sistency and  color,  hence  the  term,  but  these  features  vary  with  the 
number  and  character  of  the  cells,  and  the  presence  or  absence  of 
secondary  changes,  such  as  hemorrhages,  formation  of  cysts,  myxoma- 
tous degeneration,  and  necrosis,  all  of  which  cause  softening.  Those 
containing  bone,  cartilage,  or  much  fibrous  tissue  are  hard  in  consis- 
tency and  pale  on  section.  Sarcomata  are  usually  strikingly  de- 
ficient in  the  amount  of  intercellular  substance  compared  with  the 
number  of  embryonic  cells,  which  vary  in  size  and  shape,  are  nucleated, 
and  are  usually  without  a  limiting  membrane.  The  blood  vessels  are 
numerous  and  may  cause  the  tumor  to  pulsate;  they  consist  of 
channels,  the  walls  of  which  are  the  sarcomatous  cells,  separated 
from  the  blood  stream  by  a  single  layer  of  endothehum,  thus  account- 
ing for  the  fact  that  sarcoma  spreads  by  the  blood  vessels,  and  for 
the  frequency  of  hemorrhagic  extravasation.     Melanotic  sarcoma, 


TUMORS    AND    CYSTS  229 

lymphosarcoma,  and  sarcoma  of  the  tonsil,  testicle,  and  thyroid 
may  spread  by  the  lymphatics.  Sarcomata  may  occur  at  any  age, 
but  are  more  freciuent  in  the  first  half  of  life;  they  possess  all  the 
features  of  malignancy.  When  the  growths  are  multiple  and  wide- 
spread the  condition  is  called  sarcomatosis.  Although  some  forms  of 
sarcoma  exude  a  whitish  fluid  on  section,  it  never  resembles  the  milky 
juice  of  cancer.  It  is  sometimes  difficult  for  the  microscopist  to 
distinguish  between  round-celled  sarcoma,  gumma,  and  inflammatory 
tissue,  indeed  inflammatory  tissue  may  become  sarcomatous,  and 
sarcomatous  tissue  may  develop  into  the  maturer  forms  of  connective 
tissue.  Sarcomata  are  divided  according  to  the  size  of  the  cells  into 
(i)  the  rounded-celled  (small  and  large),  (2)  the  spindle-celled 
(small  and  large),  and  (3)  the  myeloid,  or  giant-celled. 

(i)  The  round-celled  sarcomata  (Fig.  85)  are  soft,  have  an  abun- 
dant blood  supply,  may  pulsate, 
grow  very  rapidly,  and  give  rise 
to  early  metastases,  owing  to  the 
facility  with  which  the  small  cells 
are  washed  away  by  the  blood 
stream.  A  pulsating  sarcoma 
may  simulate  an  aneurysm.  In 
some  cases  there  is  fever,  and 
this  with  a  soft  hot  swelling,  hot 
because  of  the  vascularity,  may 
lead  to  a  diagnosis  of  abscess. 
Lymphosarcoma  is  a  round-celled    ^'^-  ss.-Round-ceiied  sarcoma  of  thigh 

■'J:  ma  child. 

sarcoma     attacking     lymphatic 

glands  and  other  lymph-adenoid  tissues,  which  it  resembles  histo- 
logically, the  intercellular  stroma  forming  a  reticulum.  Chloroma 
is  a  lymphosarcoma  springing  from  the  periosteum  of  the  skull,  and 
giving  rise  to  metastatic  growths  in  other  portions  of  the  body; 
on  section  it  has  a  greenish  color,  the  nature  of  which  is  not  known. 
The  blood  changes  may  be  those  of  lymphatic  leukemia.  The 
so-called  leukemic  tumors  which  may  occur  in  splenomedullary 
leukemia  and  Hodgkin's  disease  are  probably  sarcomatous.  Alveo- 
lar sarcoma  may  be  classed  among  the  round-celled  sarcomata,  al- 
though spindle-cells  likewise  are  found  in  the  growth;  it  resembles 
cancer  in  the  formation  of  fibrous  alveoli  in  which  the  cells  are 
nested.  The  blood  vessels  run  in  the  walls  of  the  alveoli.  The 
growth  is  most  common  in  the  skin,  often  developing  from  moles  or 
warts.  Glioma  is  regarded  as  a  form  of  sarcoma  by  some  authors. 
Mycosis  fungoides  has  been  described  as  multiple  sarcomata  of  the 


230  MANUAL    OF    SURGERY 

skin,  the  histological  picture  being  that  of  a  network  derived  from 
the  connective  tissue,  in  the  meshes  of  which  are  lymphoid  cells. 
Some  authors  believe  it  to  be  bacterial  in  origin. 

(2)  Spindle-celled  sarcoma  consists  of  large  or  small  spindle  cells 
frequently  arranged  in  bundles;  the  stroma  may  be  quite  evident, 
giving  the  growth  a  fibrous  appearance  (fibrosarcoma).  These 
growths  are  apt  to  originate  in  dense  connective  tissues  (tendons, 
fascia,  periosteum),  and,  when  composed  of  large  cells,  often  show  a 
slight  degree  of  malignancy,  recurring  after  excision  but  not  giving 
rise  to  metastases. 

(3)  The  giant-celled  sarcoma  consists  of  multinucleated  giant  cell 
(myeloplaques)  and  round  or  spindle  cells.  Owing  to  the  frequency 
with  which  it  occurs  in  bones,  it  is  often  called  myeloma,  or  myeloid 
sarcoma.     Epulis  is  usually  a  giant-celled  sarcoma.     The  growth  is 

relatively  benign;  secondary  growths 
rarely  occur  and  complete  recovery  may 
follow  excision.  Some  pathologists  de- 
scribe myeloma  as  a  benign  tumor  com- 
posed of  tissue  identical  with  the  red 
marrow  of  young  bone. 

Melanotic  sarcoma,  or  melanosarcoma 
(Fig.  86),  is  usually  alveolar  in  type,  but 
the  architecture  may  be  that  of  any  of  the 
\'arieties  described  above.  The  tumor 
becomes  dark  in  color  owing  to  the  de- 
FiG.  86.— Melanotic  sarcoma  positiou  of  black  or  brown  pigment  in  and 
°    ^^'  between    the    cells.     This    pigmentation 

should  not  be  confused  with  that  due  to  extravasation,  which  is  com- 
mon in  all  forms  of  sarcoma.  The  growth  frequently  originates  in 
pigmented  structures,  such  as  moles,  warts,  or  the  retina.  Beyond 
its  pigmentation  and  its  great  virulency,  the  tumor  differs  from  other 
sarcomata  only  in  the  fact  that  it  spreads  by  the  lymph  vessels. 

Endothelioma  springs  from  the  endothelium  of  blood  vessels 
[hemangioendothelioma),  lymph  vessels  (lymphangioendothelioma), 
or  serous  membranes,  most  frequently  that  of  the  meninges,  pleura, 
or  peritoneum,  but  may  be  found  in  many  other  situations.  His- 
tologically the  growth  strongly  resembles  carcinoma,  the  endothelial 
cells  being  nested  in  acini,  hence  the  term  endothelial  cancer;  owing  to 
its  mesoblastic  origin,  however,  it  may  be  classed  among  the  sarco- 
mata. When  the  endothelial  cells  are  clumped  in  small  nodules  of  a 
glistening  pearl-like  appearance,  it  is  known  as  cholesteatoma.  Psam- 
moma  (sand  tumor),  or  duraendothelioma,  occurs  in  the  meninges, 


TUMORS    AND    CYSTS  2^1 

choroiil  plexus,  and  the  pineal  <!;lancl;  it  contains  calcareous  matter  in 
the  form  of  tine  concretions.  Perithelioma,  or  angiosarcoma ,  springs 
from  the  adventitia  of  blood  or  lymph  vessels  and  is  seen  most  fre- 
quently in  the  sk'n,  salivary  glands,  and  serous  membranes.  The 
term  does  not  apply  to  the  number  of  l)lood  vessels  in  the  growth, 
although  these  may  be  numerous  and  large  Uelangicctalic  sarcoma). 
Clylindroma,  or  plexiform  sarcoma,  is  a  perithelioma  in  which  hyaline 
or  mucoid  degeneration  takes  place  in  the  cells  surrounding  the  blood 
vessels,  the  sections  presenting  a  plexiform  arrangement.  Many 
endotheliomata  grow  slowly  without  causing  metastases,  but  recur 
after  excision;  others  are  highly  malignant. 

Hypernephroma  springs  from  the  suprarenal  gland,  or  from 
aberrant  rests  of  suprarenal  tissue,  which  may  be  found  in  many 
portions  of  the  body,  particularly  in  the  genitourinary  tract.  It  is 
said  to  be  the  most  common  mahgnant  tumor  of  the  kidney.  It  is 
usually  lobulated,  of  a  grayish-red  or  yellow  color,  and  frequently 
infiltrated  with  extravasated  blood,  giving  rise  to  blue  or  black 
areas  or  cyst-like  cavities.  The  tumor  is  generally  encapsulated; 
it  may  remain  small  and  benign,  or  grow  rapidly  and  cause  metastases 
in  the  lungs,  liver,  bones,  and  other  parts. 

The  treatment  of  sarcomata  is  early  and  thorough  excision,  which 
in  the  least  mahgnant  varieties  may  be  followed  by  permanent 
recovery,  but  in  the  small  round-celled  and  melanotic  growths  will 
very  likely  be  followed  by  recurrence.  In  those  growths  which 
affect  the  lymph  glands,  these  should  be  removed  with  the  tumor. 
In  most  cases  it  is  advisable  to  make  an  X-ray  examination  of  the 
lungs  for  metastases  before  deciding  on  operation. 

In  inoperable  sarcoma  measures  similar  to  those  mentioned  in  the 
treatment  of  inoperable  cancer  may  be  tried.  In  rare  instances 
growths  believed  to  have  been  sarcomata  have  undergone  sponta- 
neous resolution;  but  in  making  this  statement  one  should  not  fail  to 
call  attention  to  the  difficulty  often  experienced  by  the  pathologist, 
as  well  as  the  surgeon,  in  differentiating  sarcoma  from  syphilis  and 
chronic  inflammations.  Owing  to  the  fact  that  sarcomata  occa- 
sionally disappear  after  an  attack  of  erysipelas,  these  grow^ths 
have  been  treated  by  inoculations  with  the  streptococcus  of  erysipe- 
las. ]More  recently  the  toxins  instead  of  the  living  organisms  have 
been  used.  Coley's  fluid  is  a  sterilized  culture  of  the  streptococcus  of 
erysipelas  and  the  bacillus  prodigiosus.  The  initial  dose  is  19  niinim 
injected  into  or  around  the  growth;  the  dose  is  gradually  increased 
until  a  reaction  of  from  101°  to  103°  F.  is  obtained,  then  repeated 
every  two  or  three  days  for  three  weeks,  when  it  should  be  discon- 


232  MANUAL    OF    SURGERY 

tinuecl  if  there  is  no  improvement.  If  the  growth  diminishes  in  size, 
the  injections  may  be  continued  until  the  tumor  has  disappeared,  or 
until  it  begins  to  grow  again.  The  spindle-celled  sarcoma  offers  the 
best  prospects  for  cure,  while  the  round-celled  and  melanotic  forms 
are  probably  influenced  Httle  if  at  all.  Coley's  fluid  seems  to  be  of 
undoubted  value  in  a  few  cases,  and  deserves  a  trial  in  inoperable, 
but  never  in  operable  growths.  The  X-rays  or  radium  may  be  em- 
ployed, but  seem  to  have  less  effect  than  in  carcinoma. 

(in)  Teratomata  are  congenital  tumors  composed  of  epiblastic, 
mesoblastic,  and  hypoblastic  structures,  and  are  most  frequent  in  the 
ovary,  testicle,  and  sacral  region.  The  tumor  may  contain  any 
tissue,  adult  or  embryonic,  hence  may  be  benign  or  malignant.  The 
simpler  forms  contain  dermal  structures  (dermoid  cyst)  and  are  due 
to  the  healing  in  of  epiblastic  tissue  in  the  deeper  structures,  the  more 
complex  forms  are  probably  due  to  the  inclusion  of  a  blighted  ovum 
or  rudimentary  twin  (fetus  in  fetu).  They  are  to  be  treated  by 
excision. 

CYSTS 

A  cyst  is  a  new  growth  consisting  of  a  wall  and  fluid  or  semifluid 
contents.  Cysts  arise  from  (A)  the  distention  of  preexisting  spaces 
or  are  (B)  of  new  formation. 

(A)  Distention  cysts  may  be  due  to  (i)  retention,  (2)  exudation, 
or  (3)  extravasation. 

(i)  Retention  cysts  are  caused  by  the  obstruction  of  the  duct  of  a 
gland,  the  duct  beyond  or  the  acini  becoming  distended  with  the 
normal  secretion,  which  in  the  course  of  time  may  be  altered  in 
appearance  and  surrounded  by  new  fibrous  tissue.  Such  cysts  are 
most  common  in  sebaceous  glands  (wens),  mucous  glands,  salivary 
glands  (ranula),  and  in  the  breast,  pancreas,  testicle,  kidney,  and 
liver. 

(2)  Exudation  cysts  are  due  to  the  accumulation  of  fluid  in  pre- 
existing cavities  which  are  not  provided  with  an  excretory  duct. 
Serous  cysts,  acquired  bursa3,  and  hygromata  are  the  result  of  dilata- 
tion of  lymph  spaces,  ganglion  and  hydrocele  the  result  of  exudation 
into  closed  serous  cavities.  Exudation  into  functionless  canals  is 
typified  in  cysts  of  the  urachus,  vitello-intestinal  duct,  parovarium, 
paroophoron,  Kobelt's  tubes,  Gartner's  duct,  branchial  clefts,  and 
thyro-glossal  duct.  Certain  cysts  of  the  thyroid  and  ovary  (those 
arising  from  the  Graafian  folhcles)  are  exudation  cysts. 

(3)  Extravasation  cysts  follow  hemorrhage  into  a  preexisting 
cavity,  e.g.,  tunica  vaginahs  testis  (hematocele).     Extravasation  of 


TUMORS   A^[I)    CYSTS  233 

blood  into  tumors  or  other  tissues  also  may  give  rise  to  cyst-like 
cavities. 

(B)  Cysts  of  new  formation  arise  in  various  ways. 

(i)  Dermoid  cysts  are  lined  by  epithelium  and  contain  epithelial 
products,  such  as  hair,  nails,  teeth,  sebum,  mucus,  (a)  Sequestration 
dermoids  arise  from  the  inclusion  of  a  portion  of  the  epiblast  in 
situations  where  embryonic  segments  unite,  e.g.,  in  the  middle  line  of 
the  body  and  in  the  region  of  the  facial  and  branchial  clefts.  In  the 
face  the  most  common  situation  is  just  behind  the  external  angular 
process  of  the  frontal  bone  (orbito-nasal  cleft),  in  which  region  an 
opening  may  persist  in  the  skull  and  the  dermoid  be  connected  with 
the  dura  mater,  (b)  Tubulo-dermoids  are  those  developing  in 
functionless  ducts  or  obsolete  canals,  the  most  common  situations 
being  the  thyro-glossal  duct  and  the  post-anal  gut.  (c)  Ovarian 
dermoids  may  contain  not  only  dermal  structures,  but  also  meso- 
blastic  structures,  such  as  bone  and  cartilage;  in  the  latter  instance 
they  are  supposed  to  be  due  to  the  inclusion  of  a  bhghted  ovum 
(teratoma),  (d)  Implantation  dermoid  (acquired,  or  traumatic  der- 
moid) is  due  to  the  thrusting  of  epithelial  cells  into  the  subcutaneous 
tissues,  usually  as  the  result  of  a  punctured  wound. 

(2)  Blood  cysts  may  arise  from  extravasation  of  blood  (hema- 
toma). A  second  variety  often  found  in  the  neck  is  of  doubtful 
origin;  it  has  a  thin  wall  and  communicates  with  the  interior  of  a  vein. 

(3)  Cysts  due  to  foreign  bodies  are  an  effort  on  the  part  of  nature 
to  encapsulate  these  alien  substances.  Under  this  heading  may  be 
considered  also  parasitic  cysts,  two  of  which  require  notice. 

Hydatid  cyst  is  caused  by  the  echinococcus,  the  larva  of  the  tape- 
worm of  the  dog  (tenia  echinococcus) .  The  ova  are  taken  into  the 
human  ahmentary  canal  with  food  or  water;  the  embryo  is  then  freed, 
enters  the  blood  or  lymph  stream,  and  finally  lodges  in  an  organ  where 
it  forms  a  cyst.  The  wall  of  the  cyst  is  composed  of  three  layers, 
externally  a  layer  of  fibrous  tissue,  then  a  cuticular  or  lamellar  layer 
(ectocyst),  and  lining  these  a  parenchymatous  germinal  layer  (endo- 
cyst)  which  acts  as  a  budding  or  brood  membrane.  From  this  inner 
layer  heads,  or  scohces,  with  four  suckers  and  a  circle  of  booklets 
develop,  either  singly  or  in  groups  (brood  capsules),  and  form  daughter 
cysts  (Fig.  87).  The  fluid  of  a  hydatid  cyst  is  clear,  1009  to  1015 
in  Sp.  Gr.,  neutral  or  alkalin  in  reaction,  and  contains  a  trace  of 
albumin  and  a  large  quantity  of  sodium  chlorid.  Microscopically, 
the  characteristic  booklets  may  be  found.  Even  large  hydatid  cysts 
may  be  sterile,  i.e  ,  contain  no  daughter  cysts;  the  walls,  however 
show  the  characteristic  lamination.     A  multilocular  hydatid  consists 


234 


MANUAL    OF    SURGERY 


of  numerous  small  cysts  not  inclosed  by  a  mother  cyst;  they  are  most 
frequent  in  bone  and  in  the  spinal  cord.     Hydatid  cysts  may  grow 


Fig.  87.— Diagrams  of  echinococcus  cycle  (after  Leukart,  Ziegler,  and  Lendon). 

I.  The  tape- worm,  about  6  mm.  in  length,  appearing  like  chalk-white  dots  in  the  dvto- 
denum  of  the  dog.  2.  Ovum,  about  o.oi  mm.  in  diameter,  showing  six-hooked  embryo. 
2a.  Embryo  free  from  its  shell.  3.  Cyst  differentiated  into  outer  laminated  layer  and 
parenchyma.  4.  Acephalocyst  stage.  An  outer  laminated  layer  and  an  inner  paren- 
chymatous layer,  both  now  vascular,  enclosing  fluid.  5.  Brood  capsules.  6.  Brood 
capsules  showing  development  of  scolex  or  tape-worm  head.  7.  Daughter  cysts. 
8.  Daughter  and  grand-daughter  cysts.  9.  Grape-like  mass  of  daughter  cysts,  mother 
cyst  having  disappeared.  10.  Shrinkage  of  mother  cyst,  causing  parasitic  wall  to  be 
folded,  and  between  these  folds  is  vascular  fibrous  tissue  belonging  to  the  adventitious 
cyst,  the  whole  forming  a  semi-solid  or  solid  mass,  having  a  honeycomb-like  foliated 
appearance  on  section,  compared  to  the  heart  of  a  cabbage,  or  resembling  colloid  cancer. 
II.  Scolices,  with  rostellum  and  booklets  protruded  or  retracted,  like  a  vorticella,  just 
visible  as  specks  when  the  fluid  is  held  up  to  the  light,  and  measure  about  0.3  mm. 
12  and  12a.     Hooklets,  highly  magnified.      (Walsham.) 


to  a  large  size  before  the  parasite  dies,  the  contents  then  become 
inspissated,  and  may  disappear,  or  be  converted  into  a  mortar-like 


TUMORS    AND    CYSTS  235 

mass  with  calcitlcation  ot"  the  wall  of  the  cyst.  The  symptoms  of  a 
hydatid  cyst  are  those  of  pressure  on  surrounding  parts,  eosinophilia. 
and.  in  the  event  of  suppuration,  sepsis.  If  rupture  occurs  hydatid 
urticaria  or  hydatid  toxemia  may  ensue.  Hydatid  cysts  are  exceed- 
ingly rare  in  the  United  States,  and  are  most  common  in  Iceland  and 
Australia.  Any  part  of  the  body  may  be  attacked,  but  the  disease 
is  most  frequent  in  the  liver,  lungs,  kidney,  and  brain.  The  treatment 
is  excision  if  possible;  in  other  cases,  evacuation,  removal  of  the  endo- 
cyst,  and  drainage. 

The  cysticercus  ceUulosce.  which  is  the  lar\a  of  the  tenia  solium,  or 
pork  tape  worm,  gains  entrance  to  the  tissues  in  the  same  way  as  the 
echinococcus.  Cysticerci  from  the  tenia  saginata  also  have  occurred 
in  a  few  cases.  Cysticerci,  i.e.,  the  cysts,  are  usually  multiple,  hard, 
and  rarely  as  large  as  a  hazelnut.  The  symptoms  are  due  to  pressure 
and  depend  upon  the  situation.  The  favorite  sites  are  the  subcuta- 
neous tissues,  the  central  nervous  system,  and  the  eye.  Calcification 
and  suppuration  are  possibilities.  Eosinophilia  occurs.  If  favor- 
ably located  cysticerci  should  be  excised. 

(4)  Cysts  of  degeneration  such  as  arise  in  tumors  require  no 
special  comment. 

DIAGNOSIS  OF  TUMORS 

One  must  first  be  sure  that  a  pathologic  swelling  is  present. 
Xeurotic  individuals  sometimes  imagine  they  have  a  tumor  when 
they  discover  for  the  first  time  an  inequality  in  the  ribs,  a  self- 
inflated  stomach,  the  roll  of  epigastric  fat,  or  the  lobules  of  the 
breast  which  can  be  picked  up  between  the  fingers.  Phantom 
tumor  (q.v.)  and  pregnancy  may  occasionally  deceive  even  the 
most  able  chnician.  Other  forms  of  tumors  besides  neoplasms 
and  cysts  are  mentioned  in  the  following  paragraphs,  because  in 
practice  one  must  often  consider  all  these  swellings  before  making 
the  diagnosis  of  a  new  growth. 

History. —  (i)  The  family  history.  (2)  age,  (3)  nationality,  (4)  sex, 
(5)  occupation,  (6)  previous  history  of  the  patient,  and  (7)  previous 
treatment  of  the  swelling  may  have  some  bearing  on  the  diagnosis 
(see  chap.  i). 

(8)  Onset. — (a)  Sudden  onset  can  take  place  only  when  normal 
structures  or  contents  of  structures  are  suddenly  displaced,  e.g., 
fractures  of  bone;  ruptures  of  muscles  or  other  parts;  dislocation  of 
organs  (hernia,  prolapse),  joints,  muscles,  tendons,  nerves;  escape 
of  air  (emphysema,  pneumatocele),  blood  (hematoma,  hematocele. 
traumatic  aneurysm),  or  other  fluid  (extravasation  of  urine,  spurious 


236  MANUAL    OF    SURGERY 

meningocele)  into  the  tissues.  A  neoplasm  never  springs  suddenly 
into  existence,  but  having  been  present  some  time  it  may  be  suddenly 
noticed,  or  having  been  concealed  it  may  be  abruptly  extruded  from 
its  hiding  place,  e.g.,  polyps,  hemorrhoids,  loose  bodies  in  joints, 
tumors  of  the  spermatic  cord  lying  within  the  abdomen.  A  cold 
abscess  likewise  may  apparently  arise  instantaneously  when  it 
perforates  a  dense  fascia,  (h)  Rapid  onset  occurs  in  acute  inflam- 
matory processes,  edema  from  nervous  (angioneurotic)  or  hemic 
disturbances  or  from  interference  with  the  circulation,  and  in 
obstruction  to  the  ducts  of  actively  functionating  glands,  e.g. 
swelling  of  the  salivary  glands  or  gall  bladder  from  calculus,  caked 
breast,  retention  of  urine  from  stricture.  It  should  be  recalled  that 
the  constant  irritation  produced  by  inflammation,  calculi,  etc., 
may  be  the  cause  of  neoplasms,  especially  carcinoma,  and  that 
inflammation,  edema,  and  obstructive  distention  of  ducts  or  glands 
may  be  the  result  of  new  growths.  We  have  seen  several  cases 
of  acute  cancer  and  round-celled  sarcoma,  notably  about  the  jaws 
and  breast,  which  owing  to  their  rapid  development  have  been 
incised  for  abscesses.  Many  of  the  conditions  mentioned  under 
''a"  may  arise  rapidly  instead  of  suddenly  when  the  causes  are 
less  active,  (c)  Slow  onset  is  characteristic  of  chronic  inflammation, 
hypertrophies,  some  forms  of  edema,  most  neoplasms  and  cysts, 
aneurysm,  varix.  and  of  swellings  due  to  gradual  displacement 
of  parts,  e.g.,  kyphosis,  exophthalmos,  and  many  herniae.  Chronic 
inflammatory  masses  due  to  the  irritation  of  a  ligature  or  other 
foreign  body  have  occasionally  been  excised  for  neoplasms. 

(9)  The  duration  of  a  neoplasm  is  generally  a  matter  of  months 
or  years;  in  the  former  instance,  if  large,  it  may  be  malignant,  in 
the  latter  it  is  probably  benign.  Tumors  dating  from  birth,  i.e., 
congenital,  are  usually  the  result  of  malformation  or  maldevelop- 
ment,  e.g.,  hernia,  hydrocele,  branchial  cysts,  congenital  dislocations, 
meningocele,  and  teratomata,  but  include  also  hemangioma,  lymph- 
angioma, lipoma,  fibroma,  hypertrophies,  and  masses  of  callus 
from  intrauterine  fractures.  Occasionally  tumors  of  congenital 
origin  do  not  appear  or  are  not  noticed  until  some  time,  perhaps 
years,  after  birth. 

(10)  The  progress  is  indicated  b\'  the  rate  and  manner  of  growth. 
Stationary  neoplasms  are  benign.  Diminution  in  size  may  occur 
fa)  suddenly  when  the  contents  of  a  swelling  escape  from  rupture 
of  the  tumor  (e.g.,  ovarian  cyst,  intraperitoneal  abscess),  from 
dislodgement  of  an  obstruction  in  a  duct  (e.g.,  distended  urinary 
or  gall  bladder),  or  from  displaced  parts  slipping  back  into  their 


TUMORS    AND    CYSTS  237 

normal  ^lace  (e.g.,  hernia  and  prolapse),  or  (b)  gradually  from 
absorption  of  fluid  (pus,  blood,  serum,  milk,  etc.)  or  solids  (fibrin, 
granulation  tissue,  callus,  etc.),  or  from  contraction  of  fibrous  tissue 
(e.g.,  masses  of  adhesions,  withering  scirrhus). 

Increase  in  size  depends  upon  the  activity  of  the  underlying 
cause  and  the  resistance  of  the  surrounding  tissues,  (a)  Sudden 
enlargement  of  a  tumor  may  be  due  to  inflammation,  hemorrhage 
into  its  interior,  obstruction  of  circulation  (e.g.,  ovarian  cyst  with 
twisted  pedicle),  partial  obstruction  of  a  duct  becoming  complete 
(e.g.,  sudden  swelling  of  a  hydronephrotic  kidney),  augmentation 
of  contents  made  up  of  normal  structures  (e.g.,  hernia,  prolapse), 
or  rupture  of  the  tumor  (e.g.,  aneurysm),  (b)  Rapid  enlargement 
occurs  in  inflammatory  processes,  many  forms  of  edema,  some  cysts, 
and  in  acute  carcinomata  and  small-celled  sarcomata.  Other 
malignant  tumors  develop  quickly  but  not  so  fast  as  the  last  men- 
tioned, (c)  Slow  growth  generally  indicates  a  benign  neoplasm,  a 
chronic  inflammatory  process,  an  aneurysm,  a  varix,  a  cyst,  or  a 
hypertrophy,  but  may  occur  in  malignant  neoplasms  of  low  virulency. 
The  rate  of  growth  changes  from  slow  to  rapid  when  a  benign 
neoplasm  becomes  malignant,  or  a  malignant  tumor  breaks  through 
a  dense  barrier,  such  as  fascia  or  bone,  (d)  Intermittent  enlargement 
may  be  due  to  intermittent  obstruction  of  a  duct  (e.g.,  hydro- 
nephrosis and  recurrent  distention  of  the  gall  bladder  from  ball- valve 
calculus),  intermittent  activity  of  a  gland  whose  duct  is  partly 
obstructed  (e.g.,  swelling  of  the  parotid  after  meals  in  salivary 
calculus),  intermittent  interference  with  the  circulation  (e.g., 
recurrent  varix  in  repeated  pregnancies),  successive  attacks  of 
inflammation,  increased  displacement  of  normal  structures  (e.g., 
hernia  and  prolapse),  vascular  dilatation  in  growths  with  a  rich 
blood  supply  (e.g.,  nevus,  goiter,  some  sarcomata),  or  to  adventitious 
pouches  (e.g.,  esophageal  diverticulum). 

The  direction  of  the  growth  is  well  defined  by  fascia  or  other 
dense  structures  in  many  abscesses,  notably  psoas  and  palmar 
abscess,  in  extravasation  of  urine,  hernia,  effusions  into  closed 
cavities,  and  in  some  neoplasms;  or  it  may  follow  the  path  taken 
by  the  structures  involved,  e.g.,  lymphadenoma,  varices,  diffuse 
lipoma,  hypertrophies,  sarcoma  of  muscle  (in  the  early  stages). 
Carcinomata,  as  a  rule,  extend  most  rapidly  in  the  direction  of  the 
lymph  stream,  but  both  carcinoma  and  sarcoma  grow  in  all  directions 
and  infiltrate  contiguous  tissues  irrespective  of  their  structure. 
Benign  tumors  do  not  infiltrate,  they  expand,  and  push  aside  or 
compress  adjacent  parts  without  invading  them  with  tumor  cells. 


238  MANUAL    OF    SURGERY 

■  (11)  The  amount  of  pain  depends  more  upon  the  sensitiveness 
of  the  tissue  involved,  the  structure  of  the  part,  whether  loose  or 
unyielding,  the  rapidity  of  the  growth,  the  presence  or  absence  of 
intlammatory  or  obstructive  complications,  and  the  temperament 
of  the  individual,  than  upon  the  nature  of  the  tumor,  although 
with  equal  circumstances  the  pain  in  malignant  disease,  owing 
to  its  infiltrating  character,  is  more  severe  than  in  benign  neoplasms. 
It  must  be  emphasized,  however,  that  many  malignant  tumors, 
especially  in  the  early  stages,  are  painless.  The  interpretation 
of  the  situation  and  the  character  of  pain  is  given  in  chaper  i. 
Local  Examination. — (i)  The  situation  of  a  tumor  is  important 
to  establish  not  only  the  anatomical  but  also  the  pathological 
diagnosis.  Epithelial  growths,  unless  secondary,  can  arise  only 
in  epiblastic  or  hypoblastic  tissues;  connective-tissue  tumors  only 
in  mesoblastic  tissues.  Certain  tumors  have  a  predilection  for 
certain  structures  or  organs,  e.g..  a  tumor  arising  from  a  nerve  is 
almost  sure  to  be  a  neuroma,  a  fibroma,  a  myxoma,  or  a  sarcoma; 
a  tumor  of  the  stomach,  a  carcinoma.  The  tumors  common  in 
other  organs  are  mentioned  in  the  sections  on  regional  surgery. 
The  position  of  a  swelling  may  correspond  with  one  of  the  cavities 
of  the  body  or  with  the  site  of  fetal  relics  or  folds  and  thus  betray 
its  nature,  e.g..  synovitis,  bursitis,  hydrocele,  distended  urinary 
or  gall  bladder,  branchial  cysts,  meningocele.  Change  of  position 
may  occur  as  the  result  of  gravity  in  lipoma  and  hematoma;  of  a 
long  pedicle  in  ovarian  cysts,  floating  kidney,  wandering  spleen, 
and  similar  tumors;  of  attachment  to  freely  movable  structures 
like  the  intestine  or  omentum;  of  muscular  contraction  in  intus- 
susception, and  foreign  bodies  or  fecal  masses  in  the  intestine;  of 
continued  growth  (see  "Direction  of  Growth"  above);  or  as  the 
result  of  reducibility  of  the  tumor  (see  " Reducibility "  below). 
The  situation  of  a  superficial  tumor  may  be  apparent  at  a  glance. 
Deep  tumors  may  sometimes  be  located  by  palpation,  by  bougies 
(e.g.,  in  the  urethra,  bladder,  esophagus),  by  instruments  for  inspect- 
ing the  interior  of  cavities  (e.g.,  cystoscope,  proctoscope,  etc.), 
by  transillumination,  b}-  distending  a  viscus  (e.g.,  bladder,  stomach, 
colon)  studying  its  relations  with  the  mass,  by  the  X-ray,  and 
sometimes  only  by  the  pressure  symptoms. 

(2)  The  pressure  symptoms  depend  upon  the  size  and  situation 
of  the  growth.  The  skin  may  be  stretched,  thin,  bloodless,  and 
sometimes  ulcerated.  Arteries  are  more  often  displaced  than 
compressed,  although  diminution  or  abolition  of  the  pulse  beyond 
the  tumor  and  possibly  gangrene  may  occur.     A  delayed  pulse  is 


TUMORS    AND    CYSTS  239 

not  caused  l)y  pressure  but  by  aneurysm.  Obliteration  of  veins 
leads  to  edema,  varix,  and  dilatation  of  collateral  branches;  of 
lymph  vessels  to  edema  which  pits  but  slightly  on  pressure.  Nervous 
structures  are  irritated  (pain,  hyperesthesia,  spasm,  increased 
reflexes)  or  destroyed  (anesthesia,  paralysis,  trophic  changes,  loss 
of  reflexes).  Muscles  and  other  soft  tissues  may  be  stretched, 
distorted,  or  atrophied,  hones  expanded,  eroded,  or  absorbed,  some- 
times leading  to  spontaneous  fracture,  and  joints  dislocated  or 
rendered  useless.  Organs  may  be  displaced  (exophthalmos,  hernia, 
prolapse)  or  the  parenchyma  degenerated,  leading  to  grave  functional 
disturbances.  Pressure  on  the  bladder  may  lessen  its  capacity  and 
cause  frequent  micturition,  on  the  birth  canal  dystocia,  on  ducts 
retention  of  secretion,  on  the  air  passages  cough  and  dyspnea,  on 
the  esophagus  dysphagia,  and  on  the  bowel  symptoms  of  intestinal 
obstruction. 

(3)  The  size  of  a  tumor  from  a  diagnostic  standpoint  is  of  value 
only  when  considered  with  its  duration  (indicating  the  rate  of  growth) 
and  the  symptoms;  malignant  tumors  rarely  attain  a  large  size  with- 
out causing  serious  general  symptoms  or  local  degenerative  changes. 

(4)  The  shape  of  a  swelling  may  correspond  with  that  of  a 
normal  organ  (e.g.,  sarcoma  of  the  ovary,  spleen,  kidney)  or  cavity 
(e.g.,  in  synovitis  and  hydrocele).  The  form  is  often  hemispherical 
in  abscess;  globular  in  cysts;  sacculated  aneurysm,  and  soft  malignant 
tumors;  ovoid  in  lipoma;  warty  or  villous  in  papilloma;  lobulated 
in  lipoma,  adenoma,  chondroma,  epiplocele,  ganglia,  and  swellings 
due  to  inflammation  or  retention  of  secretion  in  acinous  glands 
(e.g.,  breast  and  parotid) ;  nodular  in  scirrhus;  cauliflower  in  intracys- 
tic  papilloma  and  in  ulcerating  malignant  tumors;  polypoid  in 
papilloma,  fibroma,  and  myxoma. 

(5)  The  margins  are  sharply  defined  in  encapsulated  and  benign 
growths,  dift'use  and  ill-defined  in  infiltrating  growths  and  inflam- 
matory processes. 

(6)  Mobility  of  a  growth  under  overlying  and  over  subjacent 
parts  is  generally  indicative  of  benignity  or  of  its  presence  in  or 
attachment  to  movable  structures.  In  the  latter  instance  it  will 
be  immovable  in  the  direction  in  which  the  structure  is  immovable 
(e.g.,  tumors  of  muscle,  tendons,  nerves,  and  vessels  are  movable 
perpendicularly  to  but  not  in  the  axis  of  these  structures),  or  when 
the  structure  is  made  tense  (e.g.,  muscle,  tendon),  or  when  the 
structure  is  fixed  with  the  other  hand  (e.g.,  the  breast).  A  tumor 
attached  to  a  muscle  or  its  tendon  moves  during  contraction  of 
the  muscle;  to  the  trachea  (e.g.,  goitre),  during  deglutition;  to  the 


240  MANUAL    OF    SURGERY 

liver,  spleen,  or  kidney,  during  respiration.  A  tumor  which  dis- 
appears when  a  muscle  is  contracted  lies  beneath  it,  one  which  is 
made  more  prominent  is  either  a  hernia  or  lies  superficial  to  the 
muscle.  Immobility  means  attachment  to  a  fixed  structure  (e.g., 
bone),  inflammation  or  inflammatory  adhesions,  neoplastic  infiltra- 
tion (i.e.,  malignancy),  or  confinement  beneath  tense  structures  like 
muscle  or  fascia.  The  last  may  be  recognized  by  relaxing  the  muscle 
or  fascia,  when  the  tumor  becomes  movable. 

(7)  The  consistency  of  a  solid  benign  tumor  is  that  of  the  tissue 
of  which  it  is  composed,  viz.,  bone,  cartilage,  fibrous  tissue,  fat,  etc. 
MaHgnant  growths  may  be  as  hard  as  bone  or  so  soft  that  they 
give  a  deceptive  sense  of  fluctuation;  the  softer  the  tumor  the  more 
malignant  it  is.  Fitting  on  pressure  indicates  edema  (chap,  i), 
dermoid  cyst,  blood  clot,  or  impacted  feces.  A  soft  doughy  sensation 
may  be  noticed  in  gaseous  or  fecal  tumors,  blood  clot,  dermoid  cysts, 
and  in  tuberculous  affections  of  serous  or  synovial  cavities.  The 
consistency  of  tumors  may  sometimes  be  revealed  by  the  X-ray. 
The  significance  of  crepitation  and  alteration  of  the  local  temperature, 
which  may  be  noticed  at  this  time,  are  given  in  chap,  i,  and  of 
pulsation,  thrill  and  bruit  (which  is  audible  thrill)  in  chap,  i,  and  in 
the  section  on  aneurysm  (chap.  xv). 

Fluid  tumors  are  recognized  by  fluctuation,  translucency  (chap,  i) 
exploratory  puncture,  or  in  some  cases  by  emptying  a  viscus  by  the 
natural  route,  e.g.,  catheterization  in  distended  bladder. 

Gaseous  swellings  are  due  to  the  presence  of  a  gas-containing 
viscus,  as  in  pneumocele  and  enterocele;  to  a  leak  in  an  air-containing 
structure,  as  in  cutaneous  emphysema  and  pneumatocele;  to  the 
introduction  of  the  air  from  without,  as  in  emphysema  after  closing 
a  large  wound  or  after  a  careless  hypodermoclysis;  or  to  aerogenic 
bacteria,  as  in  gas  gangrene  and  physometra.  The  tumor  is  gen- 
erally yielding  and  elastic,  hence  often  gives  a  deceptive  sense  of 
fluctuation,  and  it  is  often  reducible.  Crepitation  may  be  obtained 
when  the  gas  is  finally  divided,  as  in  pneumocele  and  cutaneous 
emphysema;  gurgling,  when  it  is  mixed  with  fluid,  as  in  enterocele; 
and  a  tympanitic  note  on  percussion,  when  sufficient  gas  is  present. 
Occasionally  bubbles  of  gas  can  be  seen,  e.g.,  in  gas  gangrene, 
and  in  certain  cases  it  may  be  evacuated  by  puncture,  incision,  or 
when  in  the  bladder  or  uterus  by  catheterization. 

Variation  in  consistency  indicates  the  presence  of  normal  tissues 
of  different  structure,  as  in  enteroepiplocele;  several  types  of  tumor 
formation,  as  in  teratoma,  adenomyxoma,  cystadenoma,  etc.;  or 
the  changes  to  be  mentioned  in  the  next  paragraph. 


TUMORS    AND    CYSTS  24 1 

Change  in  consistency,  involvin<]j  cither  a  portion  or  the  whole 
of  the  tumor,  results  in  hardening  or  softening. 

Hardening  arising  (a)  suddenly  or  rapidly  and  associated  with 
an  increase  in  size  may  be  due  to  any  of  the  conditions  mentioned 
above  under  "Sudden"  and  "Rapid  Enlargement,"  except  rupture 
of  tumors,  {b)  Gradual  hardening  with  increase  in  size  may  be  due 
to  the  increased  tension  attending  the  growth  of  cysts  and  encap- 
sulated tumors,  or  to  change  in  the  type  of  tissue  composing  the 
tumor,  e.g.,  when  a  lipoma  becomes  a  librolipoma  or  the  embryonic 
cells  of  a  sarcoma  develope  into  maturer  forms  of  connective  tissue 
(fibrous,  cartilaginous,  osseous).  Gradual  hardening  with  decrease 
in  size  is  the  result  of  absorption  or  solidification  of  the  fluid  contents 
of  a  swelling,  e.g.,  in  cysts,  abscesses,  hematomata,  aneurysms, 
thrombophlebitis;  of  resolution  of  inflammatory  processes;  of 
organization  of  granulation  tissue;  of  ossification  of  callus;  or  of 
the  contraction  of  fibrous  tissue,  e.g.,  in  cicatricial  masses  and 
withering  scirrhus. 

Softening  arising  (a)  suddenly  with  increase  in  size  is  generally 
due  to  edema.  Sudden  softening  with  decrease  in  size  may  be  due 
to  rupture  of  a  cyst,  aneurysm,  or  abscess  into  a  normal  cavity,  to 
the  partial  dislodgment  of  an  obstruction  in  a  duct  or  canal,  or  the 
partial  reduction  of  a  hernia,  (b)  More  or  less  gradual  softening 
with  increase  in  size  may  occur  when  a  benign  growth  becomes 
malignant,  when  a  malignant  growth  breaks  through  firm  fascia  or 
bone,  when  a  tumor,  usually  malignant,  undergoes  degenerative 
changes  (cystic,  mucous,  fatty,  colloid,  necrotic),  or  when  an  inflam- 
matory mass  suppurates.  It  should  be  noted  that  neoplasms  and 
cysts  may  become  inflamed  and  suppurate,  and  that  necrotic  changes, 
particularly  in  carcinoma,  may  result  in  the  formation  of  a  puruloid 
material  which  may  lead  to  the  diagnosis  of  acute  abscess,  the 
presence  of  the  growth  being  overlooked.  Gradual  softening  with 
decrease  in  size  points  to  the  absorption  of  the  contents  of  a  swelling 
whose  walls  remain  of  the  same  size,  e.g.,  serous  and  synovial 
effusions. 

Intermittent  hardening  and  softening  is  due  to  muscular  con- 
traction, e.g.,  in  intestinal  obstruction,  particularly  intussusception, 
and  in  pregnancy  (see  also  "Intermittent  Enlargement"  above). 

(8)  The  reducibility  of  a  swelling  in  part  or  as  a  whole  may 
suggest  its  nature.  Reduction  may  be  eft'ected  by  compression  or 
manipulation  in  angiomata,  varix,  aneurysm,  tumors  with  a  rich 
blood  supply,  edema,  meningocele,  reducible  hydrocele,  bursae 
comrnunicating  with  joints,  tumors  of  the  spermatic  cord,  partly 

16 


242  MANUAL    OF    SURGERY 

descended  testicle,  certain  abscesses  (e.g.,  psoas,  empyema  necessi- 
tatis), and  in  dislocations  of  normal  structures  (nerves,  tendons, 
muscle,  bone,  cartilage,  hernia,  prolapse);  by  position,  e.g.,  elevation 
or  the  recumbent  posture,  in  many  of  the  swellings  just  mentioned, 
and  flexion  of  the  knee  in  bursas  about  this  joint;  by  pressure  on  the 
artery  feeding  the  tumor  in  aneurysm  and  telangiectatic  growths; 
by  pressure  on  the  vein  supplying  the  sw^elling  in  varix  and  venous 
tumors  (in  applying  this  test  one  must  be  sure  of  the  direction  of 
the  venous  current  since  it  may  be  reversed,  as  in  varix  of  the  leg 
fq.v.);  by  catheterization  in  distended  hollow  viscera,  e.g.,  the 
urinary  bladder;  by  purgation  in  fecal  impaction;  or  by  anesthesia, 
e.g.,  in  phantom  tumor. 

The  phenomena  attending  reduction  should  be  noted.  An  entero- 
cele  disappears  with  a  gurgle,  certain  varices  with  a  thrill,  synovial 
effusions  containing  rice  bodies  with  a  peculiar  crepitus,  swelhng 
due  to  dislocated  joints,  muscles,  or  tendons  often  with  an  audible 
snap,  and  meningocele  sometimes  with  symptoms  of  cerebral  com- 
pression. 

Most  reducible  swellings  reappear  or  increase  in  size  when  maneu- 
vers opposite  to  those  mentioned  above  are  attempted,  and  those 
communicating  with  the  cerebrospinal  canal,  thorax,  and  abdomen 
may  swell  when  the  patient  strains  and  have  an  impulse  on  coughing. 
It  is  important  not  to  mistake  a  false  for  a  true  impulse  on  coughing, 
the  former  is  nonexpansile. 

(9)  A  number  of  tumors,  if  such  are  all  primary,  usually  points  to 
benignancy,  but  it  should  be  recalled  that  one  of  these  tumors  may 
undergo  malignant  changes.  Multiple  malignant  tumors  are  almost 
always  secondary. 

(10)  The  skin  over  the  growth  may  be  adherent  because  the  tumor 
lies  in  this  structure,  because  of  inflammation,  or  because  of  infiltra- 
tion with  cells  of  malignant  tumors.  A  sebaceous  cyst  is  always 
attached  to  the  skin  at  one  point,  a  subcutaneous  lipoma  at  many 
points,  as  is  shown  by  dimpling  of  the  skin  when  an  attempt  is  made 
to  pinch  it  up  between  the  fingers;  the  latter  should  not  be  confused 
with  the  multiple  depressions,  apparent  without  raising  a  fold  of  skin, 
which  occur  in  scirrhus  (see  "Carcinoma  of  the  Breast").  Mere 
tension  exerted  by  a  large  tumor  may  make  the  skin  apparently 
adherent.  The  color  of  the  skin  (chap,  i)  and  the  presence  or  ab- 
sence of  precancerous  dermatoses  (chap,  xiv)  should  be  noticed. 
Distention  of  the  superficial  veins  over  a  growth  may  be  caused  by 
any  tumor  which  obstructs  the  deeper  veins,  or  by  tumors  with  an 
abundant  blood  supply,  conspicuously  sarcoma ;  in  the  former  the 


TUMORS    AND    CYSTS 


243 


vtM'ns  distal  to  the  <,fro\vth  also  arc  c'nlar<,a'(l  and  i)erhaps  edema 
may  be  present,  in  the  latter  the  venous  engorgement  is  confined  to 
the  growth  and  the  parts  proximal  to  it  (Figs.  88,  89).  Nodules  in  the 
skin  about  a  tumor  are  usually  secondary  malignant  growths.  Ul- 
ceration of  a  benign  tumor  may  occur  from  friction,  pressure,  or 
pyogenic  infection;  it  may  be  due  to  one  of  the  infectious  granulo- 
mata,  notably  syphilis  and  tuberculosis;  and  it  is  common  in  malig- 
nant tumors  (see  "Diagnosis  of  Ulceration")-  Bleeding  from  an 
ulcerating  tumor,  aside  from  hemangioma  and  villous  papillomata, 
points  strongly  to  malignancy. 

(11)  Adjacent  lymph  glands  may  be  enlarged  in  any  form  of 
ulceration  (see  "Diagnosis  of  Ulceration,"  and  of  "Chronic  Lymph- 
adenitis"); if  ulceration  is  not  present  the  growth  is  probably  car- 
cinoma, although  as  already  stated  certain  sarcomata  may  spread 
by  the  lymph  vessels  (see  "Sarcoma")- 


Fig.  88. — A  tumor  (T)  pressing 
on  a  vein  (V)  causes  enlargement  of 
the  collateral  veins,  not  only  over, 
but  also  above  and  below  the 
growth. 


Pig.  89. — A  vascular  tumor 
(T)  not  compressing  the  vein  (V) 
causes  enlargement  of  the  vessels 
over  and  above,  but  not  below, 
the  growth. 


(12)  Exploratory  incision  to  expose  the  growth  is  employed  par- 
ticularly in  abdominal  tumors.  Incision  of  the  swelling  itself  is 
sometimes  indicated  before  proceeding  to  extirpation;  cases  have 
occurred  in  which  the  tongue  or  the  breast  has  been  excised  and  the 
swelling  found  to  be  simply  a  cold  abscess;  again,  cases  of  fibrocystic 
disease  of  the  lower  jaw  and  chronic  inflammatory  swellings  due  to 
foreign  bodies  have  been  subjected  to  formidable  operations  with  the 
belief  that  the  swelling  was  sarcomatous. 

(13)  Excision  of  a  portion  of  the  tumor  for  microscopic  examina- 
tion is  occasionally  necessary  to  establish  a  correct  diagnosis.  In 
these  cases,  whenever  possible,  the  patient  should  be  prepared  for  a 
radical  operation  and  a  section  of  the  growth  removed,  frozen,  and 
examined  at  once.  Allowing  days  to  elapse  between  the  exploratory 
excision  and  the  extirpation,  in  cases  of  malignant  disease,  may  per- 
mit of  dissemination  of  the  tumor  cells  from  the  cut  surfaces.  If 
delay  must  be  accepted  the  raw  surfaces  should  be  cauterized. 
Here  we  may  mention  the  possibility  of  making  a  diagnosis  by 
chemical  and  bacteriological,  as  well  as  microscopic,  examinations  of 


244  MANUAL    OF    SURGERY 

fluids  obtained  by  aspiration  (e.g..  in  ranula,  galactocele,  pancreatic 
cyst,  hydatid  disease,  hydronephrosis,  tuberculous  abscess) ;  of 
secretions  (e.g.,  examination  of  the  stomach  contents  in  gastric 
carcinoma);  of  excretions  (e.g.,  by  recovery  of  portions  of  the 
growth);  and  of  discharges  (e.g.,  in  the  infectious  granulomata). 

General  Examination. — Cachexia  occurs  in  malignant  tumors,  but 
as  a  late  sign,  hence  its  absence  should  not  influence  the  diagnosis  in 
the  early  stages.  Metastases  should  be  sought  for,  not  only  in  lymph 
glands,  but  in  other  portions  of  the  body,  particularly  the  lungs,  liver, 
and  the  bones;  and  a  search  made  for  evidences  of  diseases,  like 
syphihs  and  tuberculosis,  which  might  cause  a  locaHzed  swelling. 
The  heart  is  examined  as  a  matter  of  routine;  in  many  cases  of  fibro- 
myoma  of  the  uterus  it  undergoes  brown  atrophy.  Blood  examina- 
tion may  reveal  anemia;  luekocytosis;  the  hemolytic  reaction  in 
the  later  stages  of  malignant  disease;  lymphocytosis  in  chloroma, 
tuberculosis,  exophthalmic  goiter,  or  any  disease  of  the  lymph 
glands;  the  Wassermann  reaction  in  gummata;  and  eosinophilia  in 
parasitic  cysts.  Apart  from  local  conditions  the  urine  may  show  the 
Bence- Jones  albumose  in  myeloma,  sugar  and  the  Cammidge  reac- 
tion in  pancreatic  tumors. 


CHAPTER  XIV 
SKIN  AND  CUTANEOUS  APPENDAGES 

Only  those  affections  of  the  skin  which  may  interest  the  surgeon, 
and  which  are  not  dealt  with  in  other  sections  of  the  book  are  in- 
cluded in  this  chapter. 

Erythema  nodosum  must  be  mentioned,  because  its  local  manifes- 
tations may  be  mistaken  for  abscesses,  gummata,  bruises,  or  osteo- 
myelitis. It  is  most  frequent  in  young  females,  and  is  characterized 
by  fever,  and  the  formation  of  round  or  oval  nodules,  varying  in  size 
from  that  of  a  pea  to  an  area  several  inches  in  diameter,  usually 
on  the  shins,  but  occasionally  on  other  portions  of  the  body.  These 
nodules  are  at  first  bright  red,  painful,  tender,  and  often  so  soft  as  to 
give  a  sense  of  fluctuation,  but  they  should  never  be  opened,  as 
spontaneous  resolution  always  takes  place  in  the  course  of  a  few 
weeks.  As  the  swelling  subsides,  the  color  passes  through  the  various 
shades  of  a  bruise,  hence  the  term  erythema  con  tus  if  or  mis.  Since  the 
disease  is  often  associated  with  rheumatism,  and  since  similar  lesions 
may  occur  in  sepsis,  ptomain  poisoning,  and  after  the  administration 
of  certain  drugs,  notably  the  iodids,  the  bromids,  and  antipyrin,  it 
probably  is  of  a  toxic  nature.  The  treatment  is  rest  in  bed,  lead 
water  and  laudanum  locally,  and  salicylates  internally. 

Purpura  appears  as  minute  hemorrhages  (petechias)  in  the  skin 
and  the  mucous  membranes.  It  is  a  symptom  of  many  diseases,  for  a 
full  list  of  which  the  student  is  referred  to  a  text  book  on  medicine  or 
dermatology.  The  surgeon  is  interested  in  purpura  for  four  reasons, 
(i)  As  an  indication  of  spontaneous  hemorrhage  (q.v.)  it  forbids  any 
but  the  most  urgent  operation.  (2)  It  may  be  encountered  in 
surgical  conditions  like  hemophilia,  cholemia,  septicemia,  snake  bite, 
lightning  stroke,  carcinomatous  or  tuberculous  cachexia,  traumatic 
asphyxia,  and  stasis  from  venous  obstruction;  and  it  may  follow  the 
administration  of  antipyrin,  bromids,  belladonna,  copaiba,  ergot, 
mercury,  or  quinine.  (3)  It  may  give  rise  to  errors  of  diagnosis, 
unless  one  looks  for  the  spots  in  the  skin.  In  purpura  hemorrhagica 
there  may  be  bleeding  from  the  nose,  the  stomach,  the  bowel,  or  the 
kidney.  In  Henoch's  purpura  there  may  be  fever,  slight  leukocyto- 
sis, tenderness  and  rigidity  of  the  abdomen  (suggesting  appendicitis) , 
vomiting  (sometimes  of  blood)  and  constipation  (simulating  intes- 

245 


246  MANUAL    OF    SURGERY 

tinal  obstruction),  or  diarrhea  with  bloody  stools  (aping  mesenteric 
thrombosis);  the  articular  manifestations  may  be  misinterpreted  as 
due  to  some  other  joint  affection.  The  purpuric  rash  is  often  the 
last  symptom  to  appear,  and  even  when  present  may  not  be  noticed. 
Notwithstanding  the  possibility  of  making  a  mistake,  however,  if  the 
abdominal  symptoms  are  strongly  indicative  of  a  grave  surgical 
lesion  a  laparotomy  must  be  performed.  ^Mitchell  has  collected  20 
cases  in  which  the  abdomen  was  opened.  In  some  the  intestine 
appeared  normal,  in  some  there  were  petechise  and  edema,  in  eight 
there  was  an  intussusception.  (4)  In  the  treatment  of  purpura  the 
surgeon  may  be  requested  to  transfuse  blood. 

Sporotrichosis  is  caused  by  the  sporothrix  Schenckii,  which  is 
found  around  barn  yards,  on  vegetables  and  grain,  and  which  enters 
the  body  through  a  wound  or  with  the  food.  In  the  tissues  these 
organisms  are  seen  as  oval  bodies,  often  with  budding  processes;  on 
artificial  media  mycelial  filaments  and  spores  are  formed.  The 
disease  occurs  in  horses,  mules,  dogs,  and  rats,  as  well  as  in  man. 
In  man  the  lesions  may  resemble  those  of  syphilis,  tuberculosis,  or 
rarely  those  of  blastomycosis.  The  dermal  form  follows  a  trivial 
wound;  a  rat  bite  or  a  thorn  wound  is  highly  suggestive.  Painless, 
cutaneous  or  subcutaneous  nodules  appear  along  the  course  of  the 
lymphatics,  and  ultimately  soften,  discharging  a  seromucoid  pus. 
In  the  osseous  and  the  articular  forms  there  may  be  eburnation.  cold 
abscesses,  or  a  gummatous-like  degeneration.  The  disease  may 
occur  also  in  any  of  the  other  tissues  of  the  body.  If  one  only  sus- 
pects the  condition,  the  diagnosis  can  be  made  readily  by  the  bac- 
teriologist. Widal's  reaction  consists  in  an  aggliitination  of  the 
spores  by  the  patient's  blood  serum.  The  treatment  is  potassium 
iodid  internally,  with  a  weak  iodin  wash  locally.  Curettage  or  more 
extensive  surgical  measures  may  occasionally  be  necessary. 

Blastomycosis  is  an  infectious  disease  due  to  blastomycetes,  and 
is  most  commonly  found  in  the  skin  of  the" upper  extremities  and  face. 
A  few  cases  of  general  infection  have  been  reported.  The  organism 
is  spherical  or  oblong,  surrounded  by  a  double  capsule,  and  may 
contain  a  nucleus  or  spore-like  body,  vacuoles,  and  granules.  Mul- 
tiphcation  takes  place  by  budding.  Beginning  as  a  small  papule  the 
lesion  becomes  pustular  and  discharges  a  glairy,  sticky  secretion. 
The  ulcerating  surface  gradually  enlarges  and  becomes  covered  with 
soft,  friable  papillte.  The  margin,  one  of  the  characteristic  features, 
is  raised,  indurated,  and  a  dusky  red  in  color,  and  scattered  through 
it  may  be  seen  small  miliary  abscesses.  The  disease  may  last  for 
vears.     The  diagnosis  is  confirmed  by  microscopical  examination  of 


SKIN    AND    CUTANEOUS    APPENDAGES  247 

the  j)us.  The  f)roi^nosis  is  good,  provided  the  treatment  is  instituted 
early,  when  a  cure  may  be  expected  in  from  three  months  to  a  year. 
The  treatment  is  excision,  or  when  this  is  not  possible,  the  continued 
use  of  potassium  iodid  with  local  antiseptics  and  the  Rontgen  ray 
(Ricketts). 

A  boil,  or  furuncle,  is  an  acute  inflammation  of  a  limited  portion 
of  the  skin  and  subcutaneous  tissue  around  a  hair  follicle,  sweat  or 
sebaceous  gland.  Infection  is  commonly  due  to  the  staphylococcus 
pyogenes  aureus.  Bright's  disease,  diabetes,  or  any  other  condition 
which  lowers  the  general  resistance  predispose  to  crops  of  boils. 
A  boil  may  be  preceded  by  a  slight  wound  or  abrasion,  such  as  that 
which  follows  shaving,  scratching,  or  irritation  from  a  collar  button, 
but  in  many  instances  no  such  history  can  be  obtained.  Secondary 
boils  are  caused  by  infection  of  surrounding  hair  follicles  by  organisms 
from  the  primary  boil. 

The  symptoms  are  a  stinging  and  itching  sensation  due  to  the 
formation  of  a  small  red  pimple,  which  increases  in  size,  becomes  more 
painful,  and  forms  a  conical  elevation,  deep  red  in  color  and  very 
tender.  Occasionally  the  process  extends  no  further  and  the  inflam- 
mation gradually  subsides  without  suppuration  (blind  boil).  As  a 
rule  the  pain  and  swelling  increase,  the  color  becomes  more  dusky, 
and  a  pustule  forms;  this  ruptures  and  exposes  a  "core,"  or  slough, 
consisting  of  a  necrotic  sebaceous  gland  or  hair  follicle.  After 
separation  of  the  slough  the  cavity  heals  by  granulation. 

The  treatment  is  hot  fomentations,  and  incision  when  maturation 
occurs.  Tonics  are  required,  and  calx  sulphurata,  grain  Vfo  t.  d.. 
and  fresh  brewer's  yeast,  f5i  before  or  during  meals,  have  been 
recommended  to  hinder  the  formation  of  new  boils.  Vaccin  treat- 
ment may  be  tried. 

Oriental  boil  ialeppo  boil,  Buska  button,  Dehli  sore)  is  confined  to 
the  tropics  and  is  contagious.  It  begins  as  a  papule,  which  ulcerates, 
the  ulcer  healing  only  after  months  and  leaving' an  ugly  scar.  The 
treatment  is  cauterization  or  excision. 

Carbimcle  is  an  acute  inflammation  of  a  limited  portion  of  the 
skin  and  subcutaneous  tissue,  with  the  formation  of  multiple  sloughs. 
Like  a  boil  it  is  due  to  the  staphylococcus  pyogenes  aureus  and  occurs 
in  individuals  whose  general  resistance  is  depressed  by  diabetes, 
Bright's  disease,  or  any  other  debilitating  condition;  in  fact,  a  car- 
buncle is  a  boil  with  multiple  cores.  Carbuncles  are  most  frequent 
on  the  back,  nape  of  the  neck,  and  buttocks.  The  infection  enters 
a  hair  follicle,  reaches  the  subcutaneous  tissue  through  the  little 
column  of  fat  in  which  the  hair  follicle  ends,  then  spreads  laterally, 


248  MANUAL    OF    SURGERY 

and  again  finds  egress  through  columns  of  fat  {columna  adiposa)  to 
the  surface,  thus  giving  a  sieve-like  appearance. 

The  symptoms  at  the  outset  may  be  those  of  a  boil,  or  there  may 
be  a  deep  infiltration  of  the  subcutaneous  tissues.  In  either  event 
the  induration  spreads  until  in  some  cases  it  reaches  the  diameter  of 
six  or  more  inches.  All  the  symptoms  of  acute  inflammation  are 
present.  While  the  process  is  still  extending,  the  central  portion 
becomes  more  soft  and  develops  numerous  pustules,  which,  bursting, 
uncover  grayish  sloughs,  so  that  at  this  stage  a  carbuncle  resembles 
a  sponge,  the  meshes  of  which  are  filled  with  pus  and  necrotic  tissue. 
Many  of  the  openings  coalesce  while  new  ones  are  forming  at  the 
periphery.  In  a  favorable  case  the  inflammation  subsides,  the 
sloughs  separate,  and  the  cavity  heals  by  granulation.  The  con- 
stitutional symptoms  are  those  of  septic  intoxication,  septicemia,  or 
pyemia.  Carbuncles  occurring  in  vascular  regions,  such  as  the  face 
and  lips,  are  more  serious  because  of  the  danger  of  septic  phlebitis, 
which  in  facial  cases  is  prone  to  spread  to  the  cavernous  sinus.  The 
mortality  of  facial  carbuncle  is  50  per  cent. 

The  treatment  is  excision  in  those  cases  which  are  seen  early  and 
in  which  the  carbuncle  is  favorably  situated;  the  wound  is  allowed  to 
granulate  under  antiseptic  dressings.  In  other  cases  the  honey- 
combed mass  should  be  opened  freely  by  crucial  incisions,  and  as 
much  of  the  necrotic  tissue  as  possible  removed  with  forceps  and 
scissors.  The  wound  should  then  be  disinfected  with  peroxid  of 
hydrogen  and  bichlorid  of  mercury  solution,  i  to  1,000,  and  dressed 
warm  antiseptic  fomentations.  In  the  few  cases  in  which  we  have 
tried  the  x-rays,  they  had  no  appreciable  effect  on  the  carbuncle. 
The  constitutional  treatment  is  that  o"f  sepsis. 

Multiple  areas  of  cutaneous  gangrene  may  occur  in  certain 
skin  diseases,  {gangrenous  urticaria,  herpes,  erythema,  etc.);  in 
acute  infective  fevers,  possibly  as  the  result  of  embolism;  in 
hysteria,  perhaps  from  self-inflicted  injuries  with  caustics;  and  they 
may  arise  spontaneously  or  from  some  obscure  change  in  the 
nervous  system.  The  sloughs  should  be  allowed  to  separate  under 
antiseptic  fomentations,  and  treatment  directed  to  the  underlying 
cause. 

A  clavus,  or  corn,  is  a  circumscribed  hypertrophy  of  the  epidermis 
with  the  projection  into  the  skin  of  a  horny  plug  of  the  same  material. 
A  callosity  differs  from  a  corn  in  the  absence  of  the  ingrowing  central 
plug.  Corns  are  the  result  of  long  continued  pressure,  and  are  rarely 
seen  except  on  the  feet.  Hard  corns  occur  on  the  dorsal  surface  of  the 
toes,  particularly  the  little  toe,  soft  corns  between  the  toes,  where 


SKIX    AND    CUTANEOUS    APPENDAGES  249 

they  become  sodden  from  the  constant  presence  of  moisture.     Both 
varieties  are  painful,  and  may  become  inflamed  and  suppurate. 

The  treatment  is  removal  of  pressure  by  the  wearing  of  well 
fitting  shoes  or  the  application  of  a  circular  corn-plaster  of  felt. 
The  corn  itself  may  be  removed  with  a  sharp  knife  after  the  parts 
have  been  softened  by  soaking  in  hot  water.  Any  existing  deformity, 
e.g.,  hammer-toe,  should  be  corrected.  Corns  may  be  treated  also 
by  the  application  of  tincture  of  iodin,  silver  nitrate,  or  salicylic  acid; 
the  first  and  second  may  be  used  in  a  pure  form,  the  last  in  a  mixture 
consisting  of  salicylic  acid  oi,  extract  of  cannabis  indica  gr.  x,  and 
collodion  oi-  These  appHcations  may  be  used  daily  for  a  week  or 
longer.  When  the  corns  are  between  the  toes,  the  part  should  be 
frequently  washed,  dried,  dusted  with  stearate  of  zinc,  and  the  toes 
separated  by  cotton. 

Horns  {cornu  cutaneiun)  are  dry  and  solid  outgrowths  from  the 
skin  and  consist  of  cornified  epithelium.  They  sometimes  arise  from 
warts  or  from  sebaceous  glands.     They  should  be  excised. 

A  wart  {verruca)  is  a  papilloma  of  the  skin,  which  is  commonly 
pigmented  and  often  seen  on  the  hands  of  young  persons  (v.  vulgaris) 
and  on  the  back  and  arm  of  the  elderly  {v.  senilis).  It  may  be  broad 
and  flat  (v.  plana),  filamentous,  notably  about  the  face  (v. 
filiformis),  divided  into  finger-like  processes,  particularly  on  the 
scalp  (v.  digitata),  or  cronical  {v.  acuminata),  especially  about  the 
mouth,  anus,  and  genitals  see  ("Venereal  Warts").  The  surface  may 
be  smooth,  cauliflower- like,  or  horny  (-wart-Iiorn) .  Warts  are  thought 
to  be  due  to  micro-organisms,  are  often  multiple,  and  may  appear  and 
disappear  without  apparent  cause.  They  may  be  treated  by  dailv 
cauterization  with  lactic,  chromic,  nitric,  or  glacial  acetic  acid,  by  car- 
bon dioxid  snow,  by  radiotherapy,  or  by  excision. 

A  mole  is  a  circumscribed  hypertrophy  of  the  skin,  usually 
congenital,  pigmented  {nevus  pigmentosus) ,  and  covered  with  hair 
(nevus  pilosus).  White  moles  are  often  hairless  {nevus  spiliis)  and 
acquired.  A  mole  may  have  a  papillary  surface  {nevus  verrucosus) 
or  be  infiltrated  with  fat  {nevus  lipomatodes) .  The  most  interesting 
point  about  a  mole  is  that  its  base  strongly  resembles  in  structure 
an  alveolar  sarcoma;  in  fact,  it  may  in  later  life  originate  such  a 
growth,  usuafly  of  the  melanotic  variety.  Moles  so  situated  as  to 
produce  disfigurement  may  be  excised;  moles  which  are  spreading 
rapidly  must  be  excised. 

Tuberculosis  of  the  skin  occurs  in  a  variety  of  forms  fmacules, 
papules,  pustules,  tubercles),  many  of  which,  e.g.,  lichen  scrofulosum, 
eczema  scrofulosum,  etc.,  belong  strictly  to  a  work  on  dermatology. 


250  MANUAL    OF    SURGERY 

Only  those  tuberculous  lesions  of  the  skin  which  more  particularly 
concern  the  surgeon  will  be  described  here. 

Tuberculosis  ulcerosa  (ulcere  des  phthisiques)  is  an  uncommon 
form  of  tuberculous  ulceration,  occurring  almost  exclusively  at 
muco-cutaneous  junctions  as  the  result  of  internal  tuberculosis.  The 
ulcers  are  shallow,  generally  very  painful,  and  have  irregular  edges. 
The  base  is  bathed  in  a  scanty  sero-purulent  discharge  and  occasion- 
ally shows  mihary  tubercles.  The  treatment  is  that  of  tuberculosis, 
with  local  applications  of  silver  nitrate. 

Verruca  necrogenica  (anato?nical  kihercle,  butcher's  wart)  occurs 
upon  the  dorsal  surface  of  the  hand  of  pathologists,  surgeons, 
butchers,  or  others,  as  the  result  of  local  infection  with  the  tubercle 
bacillus.  It  consists  of  a  warty-like  mass  often  presenting  small 
pustules.     The  treatment  is  excision. 

Scrofuloderma  (tuberculous  gummata)  is  the  result  of  infection  of 
the  skin  or  subcutaneous  tissues,  and  consists  of  a  tuberculous  mass  of 
variable  size,  which  breaks  down  and  eventuates  in  an  ulcer.  These 
tuberculous  ulcers  have  bluish,  undermined,  irregular  edges,  and  are 
often  covered  by  a  crust,  under  which  may  be  found  pulpy  and  edema- 
tous granulations.  Healed  tuberculous  ulcers  are  characterized 
by  puckering  or  inversion  of  the  skin.  The  treatment  is  removal  of 
the  undermined  skin  and  edematous  granulations,  the  wound  being 
packed  with  iodoform  gauze.     Radiotheraphy  may  be  of  service. 

Lupus  vulgaris  is  a  tuberculous  infection  of  the  skin,  rarely 
beginning  after  the  age  of  thirty,  and  most  frequently  seen  upon  the 
face,  particularly  the  nose  and  cheeks,  although  other  portions  of  the 
body,  notably  the  extremities,  may  be  attacked.  The  disease  is 
essentially  a  local  one,  although  generalization  of  the  tubercle 
bacilli  may  occur.  It  begins  as  a  pinkish  or  I  rownish-yellow  nodule 
(lupoma) ;  other  nodules  form,  usually  along  the  course  of  the  blood 
vessels.  Thus  the  resulting  patches  are  often  irregular  or  serpig- 
inous. Pain  is  absent  and  the  lesion  may  feel  firm  or  soft.  When 
resolution  takes  place  without  ulceration,  the  nodules  shrink,  pro- 
ducing a  thin  scar  covered  by  scaly  epithelium  (lupus  exfoliativus) . 
Ulceration  with  subsequent  cicatrization  is  more  common,  the  periph- 
ery breaking  down  as  the  older  portions  are  healing.  Ulceration 
may  be  excessive  {lupus  exulcerans,  or  lupus  exedens),  or  there  may  be 
a  tendency  towards  the  formation  of  exuberant  fungoid  granulations 
(lupus  hypertrophicus).  The  disease  may  invade  adjacent  mucous 
membranes  or  destroy  adjoining  cartilage;  a  nose  thus  affected 
presents  a  "lopped-off"  appearance,  in  contradistinction  to  the 
"sunken-in"  nose  of  syphiHs.     A  lupoid  ulcer  is  irregular,  owing  to  the 


SKIN    AND    CUTANEOUS    APPENDAGES 


251 


fact  that  it  j)r()<i;resses  at  one  side  while  healinijj  at  the  other.  The 
base  is  covered  by  "apj)le-jell}'"  <i;ranuhiti<)ns,  originating  a  sero- 
purulent  discharge  that  forms  a  thick  brownish  crust.  The  margins 
are  elevated  and  thickened,  and  contain  the  lupoid  tubercles  or 
consist  of  cicatricial  tissue.  The  surrounding  parts  are  congested 
and  yellowish-red  in  color,  and  adjacent  lymph  glands  may  be  en- 
larged. The  scar  resulting  from  the  healing  of  a  lupoid  ulcer  is 
puckered,  yellowish,  and  possesses  but  little  vitaUty,  reulcerating  on 
the  slightest  provocation. 

Diagnosis. — Lupus  erythematosus  is  generally  regarded  as  non- 
tuberculous  in  origin,  although  possessing  some  features  in  common 
with  lupus  vulgaris.  When  occurring  on  the  face,  the  usual  situation, 
it  appears  as  a  symmetrical  erythema,  which  has  been  likened  to  a 
butterfly  with  outstretched  wings.  It  begins  after  puberty  and  is 
attended  with  a  branny  desquamation,  the  scales  of  which  are  in- 
spissated sebum,  derived  from 
plugs  which  distend  the  orifices  of 
the  sebaceous  glands.  Although 
ulceration  is  very  rare,  recovery 
is  attended  by  the  formation  of 
thin  cricatricial  tissue.  The  re- 
maining conditions  to  be  differ- 
entiated from  lupus  vulgaris  are 
syphilitic  ulceration,  epithelioma, 
and  blastomycosis  (q.v.). 

Treatment. — The  general 
health  should  be  attended  to, 
and  the  X-ray,  radium,  or  the 
Finsen  light  applied  locally.  If  radio-  or  phototherapy  cannot  be 
employed,  the  lesion  may  be  scarified,  excised,  or,  after  thorough 
curetting,  cauterized  with  the  actual  cautery  or  chemical  caustics. 

Epithelioma  of  the  skin  occurs  as  a  superficial,  or  flat  form,  and  as 
a  deep-seated,  or  nodular  variety. 

Superficial  epithelioma  develops  primarily  as  yellowish-red  or 
brownish  patches  scattered  over  the  surface,  or  as  a  secondary 
aft'ection  attacking  warts,  scars,  nevi,  fissures,  etc. 

Rodent  ulcer  is  a  peculiar  form  of  superficial  epithelioma,  almost 
invariably  limited  to  the  upper  two-thirds  of  the  face  (Fig.  90).  It 
occurs  in  old  age,  and  begins  as  a  little  nodule  which  ulcerates.  The 
ulcer  is  round,  oval,  or  irregular,  with  indurated  everted  edges  and  a 
smooth,  glossy,  pinkish  surface;  the  discharge  is  slight,  pain  is  absent 
adjacent  lymph  glands  are  not  involved,  metastases  do  not  occur,  and 


Fig.   90. — Rodent  ulcer. 


252  MANUAL    OF    SURGERY 

the  general  health  is  unimpaired  except  in  the  later  stages;  death 
results  from  hemorrhage  or  from  local  destruction  of  important 
organs.  The  disease  progresses  very  slowly,  sometimes  lasting 
thirty  or  forty  years,  and  occasionally  cicatrizes  in  spots,  the  scars 
later  breaking  down.  The  ulcer  advances  principally  along  the 
surface,  although  in  the  later  stages  it  extends  deeply  and  destroys 
every  thing  in  its  path,  including  the  bones.  The  disease  may 
originate  in  any  of  the  epidermal  structures. 

Deep-seated,  or  nodular  epithelioma,  may  follow  the  superficial 
form,  or  begin  primarily  as  a  nodular  growth  involving  the  whole 
skin  and  invading  the  subcutaneous  tissues.  Ulceration  occurs, 
producing  an  irregular,  offensive,  easily-bleeding  excavation,  with  an 
indurated  base;  pain  is  present  and  involvement  of  the  lymph 
glands  and  metastases  occur.  These  growths  occur  most  frequently 
on  the  scalp,  forehead,  lips,  tongue,  penis,  scrotum,  labia,  back  of 
the  hand,  and  in  cicatrices. 

Lenticular  carcinoma  is  best  seen  as  recurrences  in  the  neighbor- 
hood of  the  scar  following  amputation  of  the  breast;  it  is  alveolar  in 
structure,  and  appears  as  hard,  glistening,  reddish  or  brownish 
nodules,  which  subsequently  ulcerate,  invade  the  lymphatics,  and 
destroy  life. 

The  treatment  of  carcinoma  of  the  skin  is  early  and  thorough 
exci-sion,  with,  in  the  deep-seated  form,  the  adjacent  lymph  glands. 
Caustics  and  radiotherapy  should  never  be  employed  in  operable 
cases  of  deep-seated  epithelioma.  Superficial  epithelioma,  conspic- 
uously rodent  ulcer,  may  be  cured  by  the  X-ray,  radium,  or  the 
Finsen  light.  When  these  measures  cannot  be  carried  out,  cauteri- 
zation with  the  thermocautery,  or  by  means  of  caustic  pastes  con- 
taining potassium  hydrate,  chloride  of  zinc,  or  arsenic,  may  be  used. 

Precancerous  dermatoses  are  illustrated  by  Paget' s  disease  of  the 
nipple  (see  "Diseases  of  the  Breast");  by  the  soot-ivarts  which 
precede  chimney  sweeps'  cancer  of  the  scrotum;  by  the  dry,  thick- 
ened skin,  often  covered  with  an  acne-like  eruption,  which  precedes 
the  tar-and-paraffin  cancer  seen  on  the  hands  and  forearms  of  those 
who  work  in  coal-tar  and  paraffin;  by  keratosis  senilis,  in  which  the 
epidermis  becomes  thickened,  horny,  and  discolored;  by  xeroderma 
pigmentosum,  which  begins  with  freckle-like  pigmentations  on  the 
face  and  hands;  and  by  the  roughened,  fissured,  glossy,  skin  follow- 
ing chronic  X-ray  burns.  The  areas  of  telangiectasis,  pigmentation, 
keratosis,  and  atrophy  resulting  from  hy  per  sensitiveness  to  light,  and 
scars,  warts,  and  pigmented  moles  all  predispose  to  malignant  changes. 
De  Morgan'' s  spots  are  bright  red  nevoid  spots  often  seen  on  the  chest 


SKIN    AND    CUTANEOUS    APPENDAGES  253 

and  abdomen  of  cancerous  subjects;  they  may,  however,  occur  in 
healthy  individuals.  In  this  connection  may  be  mentioned  the 
white  patches  {leukoplakia)  which  occur  on  the  mucous  membrane 
of  the  mouth,  and  which  are  often  followed  by  epithelioma. 

Sarcoma  may  arise  from  the  connective  tissue  of  the  skin  or  occur 
as  secondary  metastatic  nodules.  Moles  sometimes  form  a  starting 
point  for  the  melanotic  variety;  some  authorities,  however,  believe 
that  the  majority  of  the  pigmented  growths  resulting  from  moles 
are  carcinomatous.  Primary  sarcoma  may  be  single  or  multiple; 
secondary  sarcoma  is  always  multiple.  The  treatment  is  excision 
whenever  practicable;  in  the  melanotic  variety  the  neighboring 
lymph  glands  also  should  be  removed.  Amputation  may  be  required. 
In  inoperable  cases  the  X-ray  and  Coley's  fluid  may  be  tried. 

Idiopathic  multiple  hemorrhagic  sarcoma  appears  first  on  the  hands 
and  feet  as  minute  reddish-brown  tumors,  which,  as  they  enlarge, 
become  bluish-red,  sometimes  resembling  angiomata.  The  growths 
are  sometimes  confluent  and  may  form  extensive  areas  of  infiltration; 
occasionally  some  of  them  atrophy,  leaving  deeply  pigmented  spots. 
The  pigmentation  is  due  to  hemorrhage.  The  disease  spreads 
slowly  to  the  trunk  and  terminates  in  death,  no  treatment  being  of 
avail. 

Mycosis  fungoides,  which  is  thought  to  be  sarcomatous  in  nature, 
is  characterized  by  the  development  of  an  urticarial  or  eczematoid 
eruption,  the  lesions  changing  to  reddish  or  bluish  tumors  and 
ultimately  undergoing  fungoid  ulceration.  No  treatment  has  any 
influence  on  the  disease,  which  is  always  fatal. 

Leukemic  tumors,  which  are  probably  sarcomatous,  may  be 
widely   scattered   in    the   skin   in    leukemia   and   pseudo-leukemia. 

Keloid  is  a  hyperplasia  of  scar  tissue,  classified  as  a  fibroma.  It  is 
covered  with  glistening  epithelium,  is  pinkish  in  color  in  white  skin, 
freely  movable  over  the  subcutaneous  tissues,  and  frequently  extends 
into  the  surrounding  skin  by  claw-like  projections,  hence  the  term. 
The  surface  of  the  growth  may  be  flat,  tuberous,  or,  more  frequently, 
irregularly  trabeculated  (Fig.  91).  Theoretically  a  distinction  is 
made  between  true,  or  spontaneous  keloid  {morphea),  which  does  not 
arise  from  a  scar,  and  false  keloid,  which  always  springs  from  a 
cicatrix.  The  belief  is  common  that  spontaneous  keloid  is  always 
preceded  by  a  minute  scar  which  has  escaped  detection.  Keloid 
occurs  most  frequently  in  the  colored  race,  is  painless,  grows  slowdy, 
and  occasionally  atrophies  in  old  age.  It  recurs  after  excision  but 
never  gives  rise  to  metastases.  The  best  treatment  is  radiotherapy. 
Excision  is  almost  useless,   even  when  follow^ed  bv  skin  grafting. 


254 


MANUAL    OF    SURGERY 


Local  injections  of  thiosinamin.  electrolysis,  elastic  compression, 
and  the  internal  administration  of  thryoid  extract  have  been  tried 
with  occasional  success. 

A  sebaceous  cyst  is  due  to  occlusion  of  the  excretory  duct  of  a 
sebacious  gland  by  dirt  or  inspissated  sebum.  It  is  rounded,  usually 
firm  but  elastic,  freely  movable  on  the  deeper  parts  unless  inflamed, 
and  invariably  attached  to  the  skin  at  one  point.  The  orifice  of  the 
obstructed  duct  can  often  be  seen,  and  occasionally  sebaceous 
matter  can  be  expressed  from  it.  These  cysts  may  be  found  wherever 
there  are  sebaceous  glands,  but  are  most  common  on  the  scalp 
(wens).  They  may  reach  a  large  size,  are  often  multiple,  and  may 
become  inflamed  and  suppurate.  \\  hen  the  overlying  skin  ulcerates, 
the  contents  putrefy  and  a  fetid  ulcer  results;  this  has  been  mistaken 


Fig.  91. — Keloid  following  a  burn. 

for  epithelioma  and.  indeed,  occasionally  undergoes  carcinomatous 
degeneration.  Calcification  sometimes  occurs.  When  the  sebum 
projects  from  the  orifice  of  the  duct,  it  may  dry  and  gradually  form, 
by  addition  from  below,  a  sebaceous  horn.  The  treatment  is  enuclea- 
tion after  incising  the  overlying  skin.  This  is  usually  very  simple, 
unless  adhesions  with  the  surrounding  parts  have  been  contracted  as 
the  result  of  inflammatory  changes.  If  any  of  the  cyst  wall  remains-; 
recurrence  is  apt  to  take  place.  Some  surgeons  transfix  the  cyst, 
and  after  emptying  it.  seize  the  cyst  wall  with  hemostatic  forceps 
and  tear  it  out.  Horns  and  ulcerating  and  inflamed  cysts  should  be 
excised. 

Onychia  {ungual  -cchitlau\  run-around)  is  an  inflammation  of  the 
m.atrix  of  a  nail,  usually  begininng  at  one  side  {paronychia),  and  fre- 
quently followed  by  suppuration  which  extends  beneath  and  around 


SKIN    AND    CUTANEOUS    APPENDAGES  255. 

the  semilunar  fold  and  loosens  ihc  nail.  Jt  is  an  alTcclion  to  which 
surgeons  and  nurses  are  peculiarly  liable,  particularly  when  run  down 
in  health.  'I'he  treatment  is  removal  of  the  loosened  portion  of  the 
nail  and  disinfection  of  the  suppurating  focus,  together  with  atten- 
tion to  the  general  health. 

Onychia  mahgna  is  a  chronic  fungating  inflammation  of  the 
matrix,  usually  of  syphilitic  or  tuberculous  origin.  The  treatment  is 
removal  of  the  nail,  antiseptic  fomentations,  and  attention  to  the 
underlying  diathesis. 

Onychauxis  is  hypertrophy  of  the  nails,  in  length,  breadth,  and 
thickness.  It  may  be  congenital,  and  sometimes  occurs  in  syphilis 
and  ichthyosis.  The  nails  are  often  furrowed  and  yellowish  or 
brownish.  Onychogryposis  (claw  nail)  is  most  frequently  seen  in 
later  life;  it  commonly  affects  the  great  toe,  and  is  frequently 
preceded  by  injury  or  neglect.  The  treatment  is  trimming  of  the 
nails  with  strong  scissors  or  bone  forceps,  or  removal  of  the  entire 
nail. 

Ingrowing  toe-nail  (onychocryptosis)  is  caused  by  narrow  shoes 
and  by  cutting  the  nail  at  the  corners  instead  of  straight  across. 
The  edge  of  the  nail,  usually  that  of  the  great  toe,  is  buried  in 
inflamed  or  ulcerating  soft  parts  at  the  side  of  the  toe.  The  treat- 
ment in  the  early  stages  is  the  introduction  of  small  pieces  of  cotton 
or  gauze  beneath  the  overgrowing  soft  parts,  the  use  of  square-toed 
shoes,  and  trimming  the  nail  square  across;  adhesive  plaster  may  be 
so  arranged  as  to  press  the  skin  from  the  edge  of  the  nail.  In  the 
presence  of  ulceration  the  best  treatment  is  removal  of  a  wedge- 
shaped  piece  of  tissue,  consisting  of  the  affected  third  of  the  nail  and 
the  underlying  matrix,  so  that  recurrence  cannot  take  place.  This 
may  be  done  under  local  anesthesia.  The  lips  of  the  wound  may  be 
approximated  with  sutures  placed  proximal  and  distal  to  the  nail. 

Plastic  surgery  in  its  broadest  sense  includes  all  operations  for  the 
correction  of  deformities,  the  filling  of  deficiencies,  and  the  removal  of 
redundant  tissue.  Plastic  operations  involving  other  tissues  than 
skin,  mucous  membrane,  and  fat,  and  plastic  operations  for  special 
conditions,  e.g.,  hare-lip,  hypospadias,  etc.,  are  dealt  with  in  other 
sections  of  the  book.  It  may  be  stated  here,  however  that  in 
general  the  nearer  a  tissue  is  histologically  to  connective  tissue  and 
the  poorer  its  normal  blood  supply,  the  better  it  stands  transplanta- 
tion, thus  skin,  fat,  fascia,  tendons,  blood  vessels,  peritoneum, 
cartilage,  and  bone  can  be  completely  separated  from  the  body  and 
after  reimplantation  survive  or  be  replaced  by  identical  material, 
while  highly  developed  cells   like  those  of  parenchymatous  organs 


256 


MANUAL    OF    SURGERY 


and  the  nervous  system  usually  perish  quickly  from  a  sudden  failure 
of  nourishment. 

Plastic  operations  for  cutaneous  defects  depend  for  their  success 
upon  strict  asepsis  (antiseptics  devitalize  the  cells),  the  relief  of  all 
tension,  thorough  freshening  of  the  parts  to  be  united,  rigorous 
hemostasis  (blood  clot  interposes  a  barrier  to  healing),  gentle  hand- 
ling of  the  flaps  or  grafts,  as  few  sutures  as  possible  (so  placed  as  not 


xlH""y 


Fig.  92. — Closure  of  a  wound  by  stretching  its  margins. 

to  cut  off  the  blood  supply,  and  for  the  same  reason  tied  loosely); 
and  the  proper  selection  of  cases,  the  debihtated,  the  syphiUtic,  and 
those  with  infected  wounds  are  unlit  for  such  operations. 

The  methods  for  fining  cutaneous  defects  are  (i)  stretching  or 
sHding  the  skin  about  the  defect.  (2)  transplantation  of  pedun- 
culated flaps,  (3)  free  transplantation  (skin  grafting). 


->    ^^P    <r- 


FiG.  93. — Relaxation  incisions. 

I.  Stretching  or  sliding  the  skin  after  it  has  been  undermined 
can  often  be  used  to  close  even  large  defects.  As  an  elliptical  wound 
is  generally  the  easiest  to  suture,  one  may  convert  into  this  type  a 
wound  of  any  other  shape  by  excising  a  portion  or  the  whole  of  its 
margins.  An  oblong  wound  may  be  changed  into  a  rhomboid  by 
pulling  on  the  upper  right  and  the  lower  left  corners,  and  then  treated 


-H4^4++- 


Fig.  94. — Relaxation  incisions. 


Y 

Fig.  95.- — Retrenchment  by  V-shaped 
incision. 


like  an  elliptical  wound,  or  two  of  the  angles  may  be  sutured,  thus 
converting  it  into  a  triangular  wound,  which  is  then  coapted  as 
shown  in  Fig.  92. 

Relaxation  incisions  are  illustrated  in  Figs.  93,  94.  If  the  skin 
between  one  of  these  incisions  and  the  defect  is  undermined  a  double 
pedunculated  flap  is  formed. 


SKIN    AND    CUTANEOUS    APPENDAGES  257 

When  one  margin  of  the  wound  is  longer  than  the  other,  the  short- 
er margin  may  be  excised  by  a  curved  incision  equal  in  length  to  that 
of  the  longer  margin,  the  longer  margin  may  be  retrenched  by  excis- 
ing a  V-shaped  piece  from  either  or  both  ends  or  from  the  middle 
(Fig.  95).  or  the  sutures  may  be  inserted  at  greater  intervals  on  the 
long  side  than  on  the  short  side  of  the  wound. 

2.  A  pedunculated  flap  consisting  of  the  skin  and  the  subcutane- 
ous tissues  should,  in  order  to  provide  for  shrinkage,  be  from  one- 
sixth  to  one-third  larger  than  the  area  to  be  filled,  unless  the  area  is  to 
be  diminished  in  size  by  stretching  or  sKding  its  margins,  and  the 
length  of  the  flap  should  not  exceed  three  times  the  width  of  the 
pedicle,  unless  there  is  an  artery  in  the  pedicle.  If.  the  pedicle 
must  be  twisted,  such  twisting  must  not  be  so  great  as  to  suppress  the 
blood  supply.  All  scar  tissue  should,  if  possible,  be  removed  from 
the  part  to  be  reconstructed,  so  as  to  provide  ample  nourishment  for 
the  flap.  Hairy  skin  should  not  be  used  where  it  would  be  unsightly, 
e.g.,  on  a  woman's  face,  or  cause  functional  trouble,  e.g.,  in  the  larynx 
or  the  bladder.  For  cosmetic  purposes,  and  for  the  comfort  of  the 
patient  during  the  treatment,  skin  from  the  immediate  neighborhood 
of  the  defect  is  to  be  preferred.  A  simple  flap  contains  only  skin  and 
subcutaneous  tissue,  a  compound  flap  includes  other  structures,  e.g., 
bone,  cartilage,  muscle.  Sometimes  cartilage,  usually  chondral,  is 
transplanted  beneath  the  skin  which  is  to  be  used  for  the  flap,  and 
after  from  four  to  six  weeks,  is  transferred  with  the  skin  to  the  part 
to  be  rebuilt.  The  wound  left  after  dissecting  up  a  flap  may  be 
closed  with  sutures  or  if  this  is  not  possible  covered  with  skin  grafts. 
Double  faced  flaps,  i.e.,  with  epithelium  on  both  sides,  may  be  needed 
to  close  a  defect  in  a  cavity  lined  with  mucous  membrane.  The  raw 
surface  of  the  flap  may  be  skin  grafted  before  or  after  its  transference 
(see  "Epidermic  Inlay"  under  "Skin  Grafting,"  Fig.  109),  two  flaps 
may  be  employed,  the  raw  surfaces  being  apposed,  or  a  single  flap 
may  be  folded  longitudinally  or  laterally.  Pedunculated  flaps  may 
be  divided  also  into  (a)  those  in  which  the  pedicle  is  not  cut  and 
(b)  those  in  which  it  is  cut. 

a.  When  the  cutaneous  pedicle  is  not  cut  the  flap,  at  least  one 
side  of  the  pedicle,  must  be  made  from  the  margins  of  the  wound 
(Fig.  96  to  105).  "Island  flaps"  are  those  completely  surrounded  by 
an  incision,  the  pedicle  consisting  of  subcutaneous  tissue  only  (Esser). 
Monks  constructed  a  lower  lid  by  using  a  flap  from  the  forehead, 
into  which  ran  the  anterior  temporal  artery.  He  dissected  out  the 
artery  with  its  veins,  and  passed  the  flap  through  a  subcutaneous 
tunnel  to  its  new  habitat,  leaving  the  vessels  under  the  skin.     Horsley 


258 


MANUAL    OF    SURGERY 


used  a  similar  procedure  to  repair  a  cheek  defect,  implanting  the 
vessels  in  an  incision. 

b.  When  the  flap  is  taken  from  the  vicinity  of  the  defect,  but 
the  pedicle  bridges  a  strip  of  skin,  or  when  the  flap  is  taken  from  a 
distant  part,  the  pedicle  is  cut  after  the  flap  has  secured  vascular 
connections  in  its  new  situation.  The  time  for  severing  the  pedicle 
varies  from  lo  days  to  three  weeks,  according  to  the  vascularity  of 


Fig.  96. 


Fig.  97. 


Fig.  98. 


msnmf: 


mini  I 


umni 


Fig.  99.] 


jjiimiiii 


Fig.    too. 


the  new  bed,  and  the  area  of  the  flap  apposed  to  the  raw  surface;  in 
some  cases,  e.g.,  in  the  repair  of  the  lips,  only  the  edge  of  the  flap 
may  be  in  contact  with  the  denuded  tissues.  Direct  transference 
means  that  the  flap  is  sutured  at  once  in  the  position  it  is  to  occupy 
permanently.  Indirect  transference  may  be  performed  in  several 
ways.  An  abdominal  flap  may  be  sutured  to  the  hand,  then,  after 
it  has  grown  in  place,  the  abdominal  pedicle  is  cut  and  the  transplant 
carried  to  the  face,  the  new  pedicle  attached  to  the  hand  being  severed 


SKIN    AND    CUTANEOUS    APPENDAGES 


259 


after  an  appropriate  interval.  A  flap  may  be  raised  from  the  chest 
the  free  end  sutured  into  an  incision  at  a  higher  level,  then  after  a 
suitable  period  the  pedicle  cut  and  transferred  to  a  still  higher  level. 


Fig.   ioi. 


-ff 


Fig.   102. 


Fig.   103. 


^>WtHt^ 


Fig.   104. 


Fig.   105. 
Figs.  96  to  105. — Sliding  flaps,  pedicle  not  cut. 

This  proceeding,  or  "waltzing"  of  the  flap  (Halstead)  may,  be 
repeated.  If  the  flap  describes  a  circle  in  its  migration  it  is  said  to 
"loop  the  loop."     A  double  pedunculated  flap  from  the  neck   is 


2  6o  MANUAL    OF    SURGERY 

sometimes  used  for  the  chin;  from  the  abdomen,  for  the  hand,  the 
hand  being  shpped  beneath  the  strip  of  skin  (Fig.  io6).  The  apph- 
cation  of  the  principles  outlined  above  is  illustrated  in  the  sections  on 
regional  surgery,  especially  those  dealing  with  the  nose  and  the  lips. 
3.  Skin  grafting  is  the  use  of  entirely  detached  portions  of  the 
skin  for  covering  raw  surfaces.  Autoplastic  grafts,  i.e.,  those  taken 
from  the  same  individual,  are  the  most  successful.  Homoplastic  grafts, 
i.e.,  those  contributed  by  relatives  or  friends,  or  obtained  from  a 
recently  amputated  limb,  seldom  "take,"  probably  because  the 
tissue  fluids  of  the  patient  have  a  cytolytic  effect  on  the  graft,  just  as 
the  blood  of  one  individual  may  cause  hemolysis  when  mixed  with 
that  of  another.  It  is  claimed  that  successful  homoplastics  grafts 
can  be  obtained  when  the  donor  and  recipient  belong  to  the  same 
blood  groups.  When  skin  is  transplanted  from  a  negro  to  a  white 
man  the  pigment  gradually  disappears  and  vice  versa.     Hetero- 


W 

Fig.   106. — Double  pedunculated  flap.      (Binnie.) 

plastic  grafts,  i.e.,  those  taken  from  the  lower  animals,  almost  always 
become  necrotic. 

Wolf's  method  (free  transplantation  of  skin)  consists  in  excising 
a  piece  of  skin  one-sixth  larger  than  the  area  to  be  filled,  removing  all 
fat  from  its  under  surface,  and  placing  it  in  the  defect,  from  which  all 
scar  tissue  should  have  been  removed,  and  in  which  the  graft  is  held 
by  the  pressure  of  the  dressings.  It  is  preferable  to  leave  the  fat  if, 
e.g.,  on  the  face,  an  indentation  is  to  be  filled.  Healing  is  complete 
in  from  three  to  five  weeks.  Hair  transplanted  with  the  graft 
usually  falls  out,  and  regenerates  irregularly,  and  the  graft  becomes 
whitish  or  yellowish.  Many  of  these  grafts  perish,  and  when  the 
dimensions  are  over  5  to  6  cm.  necrosis  is  almost  certain  to  occur. 
Thus  the  indications  for  the  Wolf  graft  are  restricted,  despite  its 
advantages,  as  compared  with  the  Thiersch  graft,  of  greater  resis- 
tance, less  shrinkage,  and  better  cosmetic  efi'ect. 

Thiersch's  method  (free  transplantation  of  epidermis)  is  quicker 
(heaUng  occurs  in  one  or  two  weeks)  and  more  certain  than  the  Wolf 
method,  and  is  generally  used  for  fresh  or  granulating  surfaces.     It 


SKIN  AND  CUTANEOUS  APPENDAGES 


261 


should  not  be  employed  when  the  part,  e.g.,  the  palm  or  the  sole,  is  to 
be  subjected  to  pressure;  in  these  cases,  if  the  area  is  too  large  for  a 
Wolf  graft,  the  raw  surface  should  be  covered  with  a  pedunculated 
flap,  taken  for  example  from  the  abdomen  in  the  case  of  the  palm, 
from  the  other  leg  in  the  case  of  the  sole.  Epidermal  grafts  are  best 
taken  from  the  arm  or  thigh.  After  the  raw  surface  has  been  disin- 
fected no  antiseptic  should  be  used.  Exuberant  granulations  are 
removed  with  a  sharp  curette  or,  better,  with  a  razor,  which  causes 
less  injury  to  the  remaining  cells,  and  bleeding  stopped  by  pressure 
with  hot  pads.  The  parts  from  which  the  grafts  are  to  be  taken 
should  be  sterilized  and  then  washed  with  salt  solution.  The  skin  is 
stretched  by  pressure  with  the  hand,  and  a  long  strip  of  epidermis,  as 
thin  as  possible,  is  shaved  off  with  a  sharp  razor  (Fig.  107).  The 
graft  lies  on  the  blade  of  the  razor  in  a  series  of  plaits  and  is  slid  onto 
the  raw  surface  by  fixing  one  end  of  the  graft  by  slight  pressure  and 
carrying  the  razor  close  to  and  parallel  with  the  wound.  (Fig.  108.) 
All  air  bubbles  should  be  pressed  from  beneath  the  graft,  which  is 


Pig.  107. 
Thiersch's  skin  grafting. 


Fig.  108. 
(Esmarch  and  Kowalzig.) 


then  covered  with  strips  of  rubber  tissue  or  silver-foil,  and  dry  sterile 
gauze.  The  wound  may  be  entirely  covered  with  such  grafts.  The 
dressing  is  changed  at  the  end  of  a  week  unless  infection  occurs. 
Instead  of  the  dressing  just  described  we  splint  the  grafts  with  a 
single  layer  of  parafiined  gauze  fastened  at  the  margins  of  the  wound 
with  collodion  thus  securing  free  drainage  into  the  outer  dressings, 
preventing  maceration,  and  allowing  change  of  the  outer  dressing  and 
irrigation  with  salt  solution  if  the  discharge  be  copious. 

Epidermic  inlay  (Esser)  is  a  form  of  Thiersch  grafting  in  which 
the  grafts  are  buried.  A  pocket,  made  beneath  the  skin  or  mucous 
membrane,  is  filled  with  heated  dental  compound,  which  after  harden- 
ing is  removed  and  covered  with  Thiersch  grafts,  raw  surfaces  out- 
ward. The  cast  is  then  replaced  in  the  pocket  and  the  wound 
sutured.  Two  or  three  weeks  later  the  wound  is  reopened  and  the 
cast  removed.  The  method  can  be  employed  to  skin  graft  the  mouth, 
to  create  a  socket  for  an  artificial  eye,  and  to  obtain  a  flap  faced  on 
each  side  with  epidermis.     (Fig.  109.) 


262 


MANUAL   OF    SURGERY 


Reverdin's  method  is  performed  by  lifting  a  small  portion  of  the 
skin  with  a  needle  and  removing  it  with  curved  scissors.  The  upper 
layer  of  the  cutis  vera  should  be  included.     A  number  of  these  grafts 


X"0^\    O  YNCCH/A  ■  PI  VIPBP. 

CAiyiry-  PRopuccp. 


>\\\;^r\^  j      -PINTAL-  COnPOUA/t>- 

WMWA  ■•ii^iii-  ZRAFT ■ 


OF  PCA/r^L-APPLIA/VCC-AII/tfl-i 


.^f-^- 


Fig.  109. — Epidemic  inlay  of  Esser  (Dorrance). 

are  placed  on  the  granulations,  raw  surface  downwards,  and  the  wound 
dressed  as  in  the  Tiersch  method.  These  grafts  at  first  apparently 
disappear  owing  to  disintegration  of  the  epidermis,  but  later  appear  as 


SKIN    AND    CUTANEOUS   APPENDAGES  263 

bluish  wliitc  sjxjIs,  from  which  the  cpithchal  growth  proceeds  in  all 
directions. 

Mangoldt's  mctJiod  consists  in  "scraping  the  sterilized  skin  with  a 
razor,  down  to  the  papillary  layer,  and  spreading  the  mixture  of 
epithelial  cells  and  blood  thus  obtained  upon  a  clean,  bloodless,  non- 
granulating  wound. " 

Mucous  membrane  from  man  or  animals  has  been  sucessfully 
transi)lanted,  and  skin  has  been  used  to  take  the  place  of  mucous 
membrane.  When  flaps  are  used  for  the  latter  purpose,  the  skin 
should  be  hairless. 

Free  transplantation  of  fat  is  followed  by  partial  (when  auto- 
plastic) or  complete  degeneration  (when  homoplastic)  of  the  trans- 
plant, the  degenerated  cells  being  replaced  by  new  cells  which  spring 
from  the  old  fat  cells  or  from  the  accompanying  connective  tissue. 
As  the  transplant  shrinks  to  some  extent  it  should  be  cut  a  little 
larger  than  seems  necessary,  and  it  should  not  be  placed  immediately 
under  a  suture  line.  Fat  transplantation  has  proved  of  value  for 
filling  cavities,  e.g.,  in  the  face  after  fracture  of  the  zygoma,  in  the 
breast  after  the  excision  of  benign  tumors,  in  bone  after  the  removal 
of  necrotic  or  carious  areas,  in  the  orbit  after  enucleation  of  the  eye; 
for  the  prevention  of  adhesions,  e.g.,  between  joint  surface  (arthro- 
plasty) ,  around  nerves  and  tendons,  between  the  brain  and  overlying 
structures;  for  the  control  of  bleeding  from  parenchymatous  organs, 
the  fat,  being  used  as  a  tampon,  is  sutured  in  place;  and,  when 
inserted  between  the  pleura  and  the  chest  wall,  for  producing  com- 
pression in  the  treatment  of  bronchiectasis  and  pulmonary  tubercu- 
losis. 

In  subcutaneous  emphysema  the  air  or  gas  is  (i)  generated  in  the 
tissues  or  comes  from  (2)  without  or  (3)  within  the  body. 

1.  Aerogenic  bacteria  are  responsible  for  the  emphysema  in  gas 
gangrene  (q.v.),  which  is  distinguished  by  sloughing  and  general  sep- 
tic symptoms. 

2.  Air  may  be  injected  beneath  the  skin  with  a  syringe  or  an 
aspirator,  or  drawn  into  a  wound,  e.g.,  in  the  axilla  or  the  base  of 
the  neck  by  the  action  of  the  respiratory  muscles,  and  fail  to  escape 
owing  to  the  valvular  nature  of  the  wound.  Air  that  is  left  in  a 
cavity  or  a  wound  at  the  conclusion  of  an  operation  is  occasionally 
forced  into  the  subcutaneous  tissues  during  subsequent  straining 
efforts. 

3.  One  of  the  air  containing  sinuses  of  the  head,  or  a  portion  of 
the  respiratory  apparatus  or  ahmentary  canal,  may,  as  the  result  of 
disease  or  injury,  communicate  wdth  the  subdermal  cellular  tissue. 


264  MANUAL    OF    SURGERY 

Of  special  interest  are  emphysema  of  the  chest  and  emphysema  of  the 
mediastinum,  which  are  discussed  in  chapter  xxiv. 

The  symptoms  in  groups  two  and  three,  aside  from  those  of  the 
condition  with  which  the  emphysema  is  associated,  are  seldom  alarm- 
ing. The  area  involved  is  usually  small,  but  may  be  so  extensive  as 
to  cover  almost  the  entire  body,  the  patient  has  the  appearance  of 
one  with  advanced  dropsy.  The  swelhng  is  puffy  looking,  painless, 
soft,  elastic,  tympanitic,  and  crepitates  on  pressure  and  auscultation. 
The  air  may  be  displaced  by  the  finger,  but  there  is  no  pitting  as  in 
edema.  The  pufhness  can  sometimes  be  increased  by  raising  the 
pressure  in  the  cavity  from  which  the  air  is  derived,  e.g.,  by  having  a 
patient  with  fracture  of  the  nasal  bones  blow  the  nose.  The  diagnosis 
of  crepitus  is  given  in  the  section  on  "Palpation,"  chapter. 

The  treatment  in  groups  two  and  three  is  that  of  the  causative 
lesion.  The  air  is  slowly  absorbed  and  rarely  demands  multiple 
punctures  or  aspiration  for  its  liberation.  Suppuraton.  which  would 
require  incision,  is  very  unusual  from  the  presence  of  air  alone. 


CHAPTER  XV 

VASCULAR  SYSTEM 

In  the  present  chapter  we  have  freely  used  the  article  by  LeConte 
and  the  author,  in  the  "American  Practice  of  Surgery,"  on  the 
"Surgery  of  the  Heart  and  Blood  Vessels,"  to  which  the  reader  is 
referred  for  an  extended  discussion  of  the  subjects  herein  treated. 

THROMBOSIS 

Thrombosis  is  the  formation  of  a  clot  (thrombus)  within  the 
circulatory  apparatus  during  life. 

The  causes  in  the  order  of  their  importance  are,  (i)  changesinthe 
vessel  walls,  the  result  of  inflammation,  necrosis,  degeneration, 
neoplastic  infiltration,  or  trauma;  (2)  changes  in  the  blood,  the  result 
of  toxemia  or  anemia;  (3)  changes  in  the  blood  current,  resulting 
in  retardation,  e.g.,  from  diminution  in  the  calibre  of  the  vessels, 
cardiac  weakness,  or  prolonged  maintenance  of  the  horizontal  posi- 
tion, or  resulting  in  the  production  of  eddies,  e.g.,  when  the  blood 
flows  into  an  aneurysm  or  a  varix.  As  coagulation  of  blood  depends 
upon  the  presence  of  fibrin  ferment,  which  causes  the  fibrinogen  and 
the  calcium  salts  of  the  plasma  to  unite  and  form  fibrin,  and  as  fibrin 
ferment  is  liberated  by  diseased  or  injured  endothelial  or  blood  cells, 
slowing  of  the  circulation  alone,  without  either  of  the  other  factors, 
will  not  cause  thrombosis,  indeed,  a  vessel  may  be  ligated  at  two 
points  without  coagulation  taking  place  for  a  long  time  between  the 
ligatures.  As  a  matter  of  fact,  one  of  the  other  factors  is  almost 
always  present;  thus,  slowing  of  the  blood  current  is  in  itself  capable 
of  inducing  nutritive  changes  in  the  vessel  walls,  and  in  the  enfeebled 
circulation  attending  fevers  there  is  toxemia  and  often  degenerative 
alternations  in  the  vascular  tunics. 

The  nature  of  the  thrombus  depends  upon  whether  it  is  formed 
slowly  from  a  moving  current  of  blood  (white  thrombus)  or  is  the  result 
of  complete  stasis  (red  thrombus) .  The  white  thrombus  is  composed 
of  gradually  deposited  white  corpuscles  and  fibrin;  when  a  consider- 
able number  of  red  corpuscles  enter  into  its  formation  it  is  called  a 
mixed  thrombus.  The  clot  which  is  first  formed  (primary,  or  auto- 
chthonos  thrombus)    usually   begins   as   a  parietal  mural   thrombus, 

265 


266  MANUAL    OF    SURGERY 

which  gradually  enlarges  until  it  fills  the  lumen  of  the  vessel  {occlud- 
ing, or  obturating  thro?}2bus) .  It  may  then  by  subsequent  additions 
{induced  thrombus)  become  a  continued,  or  propagating  thrombus, 
usually  extending  in  the  direction  of  the  blood  current.  The  term 
secondary  is  applied  to  induced  thrombi  and  to  those  forming  about 
an  embolus.  A  thrombus  is  generally  adherent  to  the  vessel  walls 
and  its  advancing  end  conical.  The  end.  e.g.,  when  it  projects  into  a 
collateral  vessel,  may  be  washed  away  as  an  embolus  (Fig.  no),  or 
the  entire  thrombus  may  loosen  and  float  into  the  blood  stream. 
The  terms  infective  and  aseptic,  or  bland,  refer  to  the  presence  or 
absence  of  bacteria. 

The  changes  which  a  thrombus  may  undergo  are  (a)  organization 
i.e.,  the  clot  is  replaced  by  fibrous  tissue  as  in 
repair  elsewhere;  (b)  canalization  as  the  result 
of  incomplete  organization,  thus  re-establishing 
the  circulation;  (c)  calcification,  forming  in  the 
veins  phleboliths  and  in  the  arteries  arterioliths; 
and  (d)  liquefaction  or  softening  the  result  of 
aseptic  degeneration  (simple  softening)  or  sup- 
puration (septic  softening),  causing  embolism 
and  in  septic  softening  pyemia. 

LocaUzation   of  Thrombi. — Cardiac  thrombi 

FiG.iio.  —  A  . 

Thrombus.  B.  Em-  are  of  no  practical  importance  to  the  surgeon. 
detachment  of  the  end  Arterial  thrombi  are  most  frequent  in  the  lower 
of  the  thrombus  which    extremity  as  the  result  of  injury,  endarteritis,  or 

projected  mto   the        ,         .  .  .  ^      ^         r  a  r^ 

larger  vessel.  Arrow  the  impaction  of  an  embolus  (see  Gangrene 
WoJTdSefm''''"''  °^  and  Embolism").  Venous  thrombi  are  much 
more  common  than  the  other  varieties,  because 
of  the  comparatively  sluggish  circulation  in  the  veins,  the  presence  of 
valves,  and  the  composition  of  venous  blood,  especially  the  increased 
amount  of  CO2.  Venous  thrombosis,  unlike  that  occurring  in  the 
arteries,  usually  attacks  the  veins  on  the  left  side  of  the  body.  The 
left  lower  limb  is  the  favorite  site,  owing  to  the  greater  length  and 
obliquity  of  the  left  common  iliac  vein,  which  is  crossed  by  the  right 
common  iliac  and  the  left  internal  iliac  arteries,  and  which  may  be 
pressed  upon  also  by  a  loaded  rectum.  Capillary  thrombi  are  gen- 
erally due  to  local  conditions,  such  as  injuries,  severe  inflammations, 
etc. ;  when  the  larger  vessels  are  blocked,  the  capillaries  remain  patent 
unless  gangrene  follows. 

The  results  of  thrombosis  depend  upon  the  location  and  the 
extent  of  the  thrombus,  the  rapidity  with  which  it  is  formed,  and  the 
condition  of  the  collateral  vessels.     Apart  from  the  constitutional 


VASCULAR    SYSTEM  267 

symptoms,  which  vary  according  to  whether  the  thrombus  is 
septic  or  aseptic,  and  the  Habihty  to  embolism,  the  phenomena 
are  mainly  those  of  obstruction  to  the  blood  stream,  the  sym})toms 
and  treatment  of  which  are  given  in  the  sections  on  "Embolism," 
"Contusions  of  Arteries,"  and  "Phlebitis."  Thrombotic  gangrene 
is  discussed  under  "Gangrene,"  post-operative  thrombosis  under 
"Phlebitis." 

EMBOLISM 

Embolism  is  the  sudden  blocking  of  a  blood  vessel  by  a  foreign 
body  {embolus)  which  has  been  brought  by  the  blood  stream  from 
some  more  or  less  distant  part.  Emboli  are  usually  detached  por- 
tions of  thrombi,  but  they  may  be  vegetations  from  the  valves  of  the 
heart,  detached  atheromatous  plates,  fat  globules,  air  bubbles, 
portions  of  tumors,  cells  from  some  of  the  normal  structures  of  the 
body,  masses  of  bacteria,  or  parasites,  such  as  the  scolices  of  the 
echinococcus  and  the  filaria  sanguinis  hominis.  Various  forms  of 
dust  when  inhaled,  and  particles  of  paraffin  and  insoluble  prepara- 
tions of  mercury  when  injected  subcutaneously,  may  float  off  into  the 
blood  stream  as  emboli. 

The  site  of  impaction  of  an  embolus  depends  on  its  origin. 
Those  arising  in  the  area  drained  by  the  portal  vein  lodge  in  the  liver; 
those  arising  in  the  general  venous  circulation  pass  through  the  right 
heart  and  lodge  in  the  lungs;  and  those  from  the  left  heart  or  aorta 
may  lodge  in  any  portion  of  the  body.  Rarely  an  embolus 
originating  in  a  vein  finds  its  way  into  the  arterial  circulation  through 
a  patent  foramen  ovale  {crossed,  or  paradoxical  embolism)  and  still 
more  rarely  is  it  transported  in  a  direction  opposite  to  that  of  the 
blood  stream  {retrograde  embolism).  An  embolus  usually  lodges  at 
the  point  where  a  vessel  suddenly  diminishes  in  size,  e.g.,  where  a 
large  branch  is  given  off  or  where  bifurcation  takes  place. 

The  effects  of  embolism,  which  depend  upon  the  size,  seat,  and 
nature  of  the  embolus,  and  the  condition  of  the  collateral  circulation, 
may  be  studied  under  two  headings:  (i)  At  the  seat  of  impaction  an 
embolus  induces  secondary  thrombosis,  and  the  mass  may  undergo 
the  changes  already  described  under  "Thrombus."  Non-absorbable 
foreign  bodies,  if  minute,  may  be  transported  by  the  leukocytes  to  the 
liver,  spleen,  or  bone  marrow;  larger  foreign  bodies  are  encapsulated 
with  fibrous  tissue.  Animal  parasites  perish  and  are  absorbed  or 
encapsulated,  or  penetrate  the  vessel  wall  and  develop  in  the  sur- 
rounding tissues.  Tumor  cells  may  proliferate  and  give  rise  to 
metastatic  growths.     Bacteria  may  produce  changes  identical  with 


206  MANUAL    OF    SURGERY 

those  at  the  original  point  of  infection.  Embohc  aneurysms  are 
thought  to  be  caused  by  a  softening  of  the  vessel  wall,  the  result  of 
bacterial  activity  (see  "Aneurysm").  (2)  The  parts  supplied  by  an 
embolized  artery  become  anemic,  but  if  there  is  an  efficient  collateral 
circulation  the  anemia  may  disappear  and  no  harm  result.  If  an 
embolus  blocks  a  terminal  artery  (i.e.,  one  having  no  collateral 
anastomoses,  except  capillary,  with  adjacent  arteries,  such  as  occur 
in  the  brain,  retina,  spleen,  kidney,  and  lung)  or  one  with  a  poor 
collateral  circulation,  the  part  beyond  becomes  gangrenous;  in  the 
viscera  this  area  is  called  an  infarct,  and  is  wedge-shaped  with  the 
base  towards  the  periphery  of  the  organ.  The  infarct  may  remain 
bloodless  (white,  or  anemic  infarct),  or  become  infiltrated  with  blood 
{red,  or  hemorrhagic  infarct),  which  comes  from  adjacent  capillaries 
and  passes  through  the  altered  vessel  walls  of  the  part.  In  either  case 
subsequent  organization  occurs  and  the  area  remains  as  a  scar,  which 
may  be  pigmented  in  the  hemorrhagic  infarct,  or  calcified  especially 
in  the  lungs;  occasionally  infarcts  in  the  brain  form  cysts.  If  the 
embolus  is  septic  the  infarct  undergoes  moist  septic  gangrene  or 
forms  an  abscess  {metastatic  abscess). 

The  symptoms  of  emboHsm  are  sudden  severe  pain  at  the  point  of 
impaction  or  in  the  ischemic  area;  absence  of  pulsation,  which  may  be 
detected  in  obstruction  not  only  of  superficial  arteries  but  also  of  any 
artery  having  superficial  branches;  hardening  of  the  vessel  at  the  site  of 
the  embolus;  increase,  after  a  time,  in  the  number  and  size  of  the 
collateral  vessels;  rise  in  the  general  blood  pressure  at  the  time  of 
occulsion  of  a  large  artery  (causing,  if  the  abdominal  aorta  is  affected, 
acute  dilatation  of  the  heart,  edema  of  the  lungs,  bloody  stools,  etc.), 
gradually  diminishing  with  the  establishment  of  the  collateral  circu- 
lation; and  in  the  ischemic  area  pallor,  fall  of  temperature,  hypesthesia, 
and  paresis,  followed,  in  the  event  of  gangrene,  by  the  discoloration 
of  gangrene,  anesthesia,  and  paralysis.  Hemorrhage,  as  a  manifesta- 
tion of  infarction,  may  show  itself  externally  when  the  lung  (hemo- 
ptysis), kidney  (hematuria),  or  bowel  (bloody  stools)  is  affected. 
The  remaining  symptoms  of  infarction  are  impairment  or  abolition 
of  the  special  functions  of  the  organ  affected.  Pulmonary  embolism 
is  discussed  below,  mesenteric  embolism  in  chap,  xxvii;  for  the  details 
of  infarction  of  other  viscera  the  student  is  referred  to  a  text-book  on 
internal  medicine. 

Diagnosis  between  Embolism  and  Thrombosis. — The  onset  is 
sudden  in  embolism,  gradual  in  thrombosis.  It  may,  however,  be 
slow  in  the  former  if  the  embolus  does  not  at  once  completely  occlude 
the  artery,  and  abrupt  in  the  latter  if  the  thrombus  forms  rapidly. 


VASCULAR    SYSTEM  269 

The  duration  of  llic  symptoms  may  he  brief  in  c'ml)()lism,  because  the 
collateral  vessels  promptly  dilate.  When  an  artery  is  slowly  oc- 
cluded the  collateral  vessels  progressively  enlarge,  so  that  by  the 
time  the  blood  stream  is  completely  arrested,  they  are  incapable 
of  the  further  dilatation  required  to  nourish  the  affected  part,  hence 
the  symptoms  are  permanent  or  of  long  duration.  If,  therefore,  the 
collateral  vessels  are  enlarged  at  the  onset  the  condition  is  probably 
thrombosis.  The  finding  of  the  causative  lesion  may  be  difficult  or 
impossible.  Embolism  is  so  much  more  frequent  in  arteries  that, 
in  the  absence  of  a  definite  cause  for  thrombosis,  the  condition  is 
generally  regarded  as  embolism,  even  when  the  source  of  the  embolus 
cannot  be  discovered. 

The  treatment  is  first  prevention  (see  "Pulmonary  Embohsm"). 
The  measures  to  be  taken  to  prevent  gangrene  in  embolism  of  the 
arteries  of  the  extremities  are  identical  with  those  mentioned  under 
"Senile  Gangrene."  Removal  of  an  embolus  in  an  accessible  region 
is  possible.  The  treatment  of  embolic  gangrene  and  of  mesenteric 
embolism  is  given  in  the  sections  dealing  with  these  subjects.  The 
treatment  of  other  forms  of  visceral  infarction  belongs  to  the  phy- 
sician, if  we  except  the  incision  of  secondary  abscesses,  and  the 
excision  of  destroyed  organs,  e.g.,  spleen  and  kidney. 

Pulmonary  embolism  may  follow  thrombosis  due  to  disease  or 
injury  (see  "Thrombosis"  and  "Phlebitis");  labor,  owing  to  the 
increased  coagulability  of  the  blood,  the  trauma  of  childbirth,  the 
wide  veins  of  the  uterus,  and  the  contractions  of  the  uterus; 
the  injection  of  coagulating  fluids  into  venous  tumors,  of  paraffin  for 
cosmetic  purposes,  and  of  mercury  in  syphilis;  and  certain  operations 
(see  "Postoperative  Phlebitis"). 

The  S3miptoms,  excluding  infective  emboli,  which  give  rise  to 
septic  processes,  depend  upon  the  size  of  the  embolus  and  the  condi- 
tion of  the  pulmonary  circulation.  I.  Minute  emboli  give  no  symp- 
toms. 2.  Emboli  large  enough  to  block  a  medium  sized  branch  of 
the  pulmonary  artery  may  be  followed  by  trifling  symptoms,  owing 
to  the  number  and  large  size  of  the  capillaries  which  supply  the 
affected  area.  If,  however,  the  pulmonary  circulation  is  sluggish, 
hemorrhagic  infarction  may  occur,  the  symptoms  being  those  of 
pleuropneumonia.  Bloody  expectoration  may  be  absent  and 
necrosis  of  the  infarct  does  not  necessarily  follow.  Many  cases  of 
pleurisy  and  mild  pneumonia,  appearing  "within  a  few  days  or  a  week 
after  operation,  are  in  reality  due  to  embolism.  3.  A  large  embolus 
occluding  the  pulmonary  artery  or  one  of  its  main  branches  causes 
death  within  a  few  minutes.     If  the  vessel  is  not  completely  blocked 


270  MANUAL   OF    SURGERY 

life  may  be  prolonged  for  hours,  or  recovery  may  follow.  In  these 
cases  the  patient  suddenly  complains  of  severe  pain  about  the  heart 
and  dyspnea;  the  respirations  are  rapid,  the  face  cyanotic,  the  eyes 
protruding,  the  pupils  dilated,  the  cervical  veins  swollen,  and  the 
pulse  quick,  weak,  and  perhaps  irregular.  In  other  cases  there  is 
dehrium,  coma,  or  convulsions.  At  the  onset  examination  of  the 
chest  may  reveal  nothing  abnormal;  later,  signs  of  edema  of  the  lungs 
appear.  Excluding  injuries  to  the  major  veins,  emboli  sufficiently 
large  to  block  the  main  pulmonary  vessels  rarely  occur  before  the 
second  or  third  week  of  phlebitis  or  after  the  sixth  week.  The  acci- 
dent often  follows  some  movement,  particularly  sitting  up  in  bed, 
which  necessitates  acute  flexion  of  the  groin,  thrombosis  being  most 
frequent  in  the  left  femoral  vein.  The  prophylactic  treatment  is 
that  of  phlebitis.  Embolic  pneumonia  is  managed  like  ordinary 
pneumonia.  In  occlusion  of  the  pulmonary  artery  or  one  of  its  large 
branches,  if  the  patient  lives  long  enough,  cardiac  stimulants,  oxygen, 
and  perhaps  bleeding  may  be  employed.  Trendelenburg  suggests 
thoracotomy,  incision  of  the  pulmonary  artery,  and  extraction  of  the 
embolus;  this  has  been  attempted  in  several  cases,  without,  however, 
a  single  recovery. 

Air  embolism  may  occur  during  the  administration  of  an  intra- 
uterine douche  after  labor,  transfusion  of  blood,  intravenous  infu- 
sion, and  especially  during  operations  at  the  base  of  the  neck  when 
the  veins  are  gaping  from  pathological  change,  anatomical  disposi- 
tion, or  the  result  of  traction.  The  amount  of  air  which  might  be 
introduced  into  a  vein  by  the  ordinary  hypodermic  syringe  would 
probably  be  insufficient  to  cause  serious  trouble.  It  is  necessary 
that  a  large  amount  of  air  be  introduced  suddenly. 

The  symptoms  are  a  gurgling  sound  due  to  the  sucking  of  air  into 
the  vein,  extreme  pallor  or  Hvidity  of  the  face,  marked  acceleration 
and  then  cessation  of  the  pulse  and  respirations,  and  occasionally 
a  gurgUng  sound  over  the  heart.  There  may  be  convulsions  preceding 
death,  which  usually  takes  place  within  a  few  minutes,  although  it 
may  be  postponed  for  several  hours  or  even  days.  The  cause  of  these 
symptoms  is  overdistention  of  the  right  heart  and  the  pulmonary 
vessels  with  air,  and  air  embolism  of  the  coronary  and  cerebral 
arteries. 

The  treatment  is  immediate  pressure  on  the  wounded  vein  to  pre- 
vent the  further  entrance  of  air.  Blood  may  be  withdrawn  from  a 
vein  of  the  arm  to  relieve  the  distention  of  the  heart,  cardiac  stimu- 
lants given  subcutaneously,  and  artificial  respiration  performed. 
Puncture  of  the  right  auricle  with  an  aspirating  needle  has  been 
proposed. 


VASCULAR    SYSTEM  27 1 

Fat  embolism,  according  to  some  authors,  may,  despite  the  ob- 
stacle presented  by  the  lymph  glands,  be  the  result  of  lymphatic 
absorption  alone,  but  most,  while  conceding  that  lipemia  may  thus 
arise,  believe  that  in  fat  embolism  the  fat  usually  enters  the  blood 
stream  solely  or  principally  through  the  open  ends  of  veins.  The 
condition  may  follow  injuries  of  fatty  tissue  in  any  part  of  the  body, 
but  is  most  frequent  after  fractures  of  long  bones,  because  of  the 
abundant  liquid  fat  in  the  medulla  of  these  bones,  because  the 
injured  osseous  veins  remain  gaping,  because  of  the  great  pressure 
exerted  by  extravasated  blood  and  inflammatory  exudate  confined 
to  a  bony  canal,  and  because  of  the  motion  to  which  a  broken  bone  is 
subjected  during  transportation,  diagnosis,  and  reduction.  Next  in 
etiologic  frequency  ranks  the  forcible  bloodless  correction  of  de- 
formities, especially  of  the  knee,  during  which  the  spongy  epiphyses 
are  violently  compressed  and  perhaps  crushed.  Fat  embohsm  is 
rare  in  infancy  and  old  age,  owing  to  the  small  quantity  of  adipose 
tissue  in  the  medulla  at  these  periods.  As  with  air,  it  is  probable 
that  a  large  quantity  of  fat  must  be  introduced  into  the  circulation 
in  a  short  time  in  order  to  produce  serious  symptoms;  indeed,  a  small 
quantity  of  fat  is  normally  present  in  the  blood. 

The  s3'Tnptoms  are  similar  to  those  produced  by  other  forms  of 
emboli.  The  fat  is  washed  through  the  right  heart  to  the  lungs, 
where  it  fills  the  vessels,  producing  sudden  death;  or,  if  the  quantity 
be  smaller,  severe  pain,  dyspnea,  rapid  pulse,  hurried,  shallow  res- 
pirations, cyanosis,  and  sometimes  hemoptysis.  At  the  onset  the 
temperature  is  apt  to  be  subnormal,  later  it  ascends.  The  physical 
signs  are  at  first  indefinite;  there  may  be  a  normal  percussion  note, 
restriction  of  the  respiratory  excursion,  and  coarse  rales;  if  the 
patient  survives,  signs  of  consolidation  often  appear.  If  the  oil 
globules  are  forced  through  the  pulmonary  capillaries,  there  may  be 
fat  in  the  urine  or  total  supression  of  urine,  and  symptoms  of  em- 
bolism of  the  brain  (convulsions,  paralysis,  coma,  etc.).  In  the 
pulmonary  form  the  symptoms  may  appear  in  from  one  to  several 
hours  after  the  trauma;  in  the  cerebral  form  the  onset  may  be  delayed 
for  a  day  or  tw^o.  This  free  interval  serves,  in  differential  diagnosis, 
to  exclude  shock  and  concussion  of  the  brain,  both  of  which  immedi- 
ately follow  an  injury.  The  relatively  brief  duration  of  the  free 
interval  distinguishes  fat  embolism  from  clot  embolism,  which  is 
usually  postponed  for  a  week  or  longer  after  an  operation  or  injury. 
In  the  cerebral  form,  however,  this  free  interval  has  been  misinter- 
preted, and  the  patient  trephined  for  intracranial  hemorrhage,  a 
condition  that  may  be  recognized  by  the  symptoms  of  compression 
of  the  brain. 


272  MANUAL    OF    SURGERY 

In  order  to  prevent  fat  embolism,  injured  fatty  tissues  should  be 
kept  at  rest,  and  if  there  is  much  tension,  resulting  from  the  accumula- 
tion of  wound  fluids,  stitches  should  be  removed  or  incisions  made. 
In  dealing  with  ankylosis  of  large  joints,  particularly  if  the  X-ray 
shows  marked  osseous  atrophy,  gradual  correction  or  arthroplasty 
may  be  safer,  at  least  so  far  as  fat  embolism  is  concerned,  than 
forcible  bloodless  correction,  which  is  particularly  dangerous  if 
several  large  joints  are  attacked  at  the  same  time.  Reiner  suggests 
that  before  removing  the  Esmarch  band  at  the  completion  of  an 
orthopedic  operation,  a  cannula  be  introduced  through  the  saphenous 
vein  into  the  femoral  vein,  in  order  to  allow  any  fat  that  may  have 
entered  the  vein  to  escape.  The  treatment  of  the  condition  itself, 
in  the  acute  cases,  is  external  heat,  cardiac  stimulants,  and  artificial 
respiration.  The  wound  should  always  be  opened  to  prevent  the 
fresh  entrance  of  fat  into  the  circulation.  The  later  treatment  is 
that  of  the  complications.  In  a  case  of  fat  embolism  following  a 
fracture  of  the  radius  Willms,  who  accepts  the  lymphatic  theory  of 
fat  absorption,  created  a  temporary  fistula  of  the  thoracic  duct  in 
the  neck.     The  patient  recovered. 

THE  HEART  AND  PERICARDIUM 

Over  distention  of  the  heart  with  blood,  the  result  of  acute 
pulmonary  affections,  or  with  air  from  air  embolism,  has  been 
treated  by  tapping  the  cavity  of  the  heart.  As  the  right  auricle 
suffers  most  from  this  overdistention  owing  to  the  thinness  of  its 
walls,  it  is  selected  for  puncture  (paracentesis  auricidi).  The  needle 
may  be  introduced  in  the  third  intercostal  space  at  the  right  edge 
of  the  sternum  and  pushed  directly  backwards.  It  traverses  the 
anterior  edge  of  the  right  lung  and  the  pericardium  before  reaching 
the  auricle.  The  operation  is  attended  with  the  danger  of  a  fatal 
hemorrhage  and  should  rarely,  if  ever,  be  performed. 

Wounds  of  the  heart  may  be  produced  by  penetration  from 
without,  e.g.,  by  gunshot  or  stab  wounds,  fractured  ribs,  or  by  foreign 
bodies  from  the  esophagus,  stomach,  or  bronchus.  The  heart 
may  burst  as  the  result  of  blunt  force  to  the  thorax  or  epigastrium 
and  it  may  rupture  spontaneously  (disease  of  the  myocardium  or 
coronary  artery,  neoplasms,  gummata,  echinococci,  abscess, 
aneurysm,  etc.). 

Symptoms. —  Instantaneous  death,  which  probably  results  from 
injury  to  the  nervous  mechanism  of  the  heart,  is  very  rare,  and 
more  apt  to  follow  a  severe  blow  over  the  heart  or  epigastrium  than 


VASCULAR    SYSTEM  273 

a  penetrating  wound  (so-called  concussion  of  the  heart).  The 
symptoms  in  a  case  not  immediately  fatal  are  those  of  acute  anemia 
or  of  compression  of  the  heart,  depending  upon  whether  the  blood 
escapes  into  the  pleural  cavity  or  externally,  or  ujion  its  retention 
in  the  pericardium.  Occasionally  the  patient  may  walk  or  even 
run  for  a  considerable  distance  before  falling  to  the  ground.  When 
the  blood  escapes  into  the  pleural  cavity  (the  pleura  is  injured  in 
over  90  per  cent,  of  the  cases)  there  will  be,  in  addition  to  the  symp- 
toms of  acute  anemia  (see  "Hemorrhage"),  the  signs  of  a  pneumo- 
hemo-thorax.  Palpation  may  detect  the  apex  beat.  A  whizzing 
sound  due  to  the  presence  of  air  in  the  pericardium,  a  friction 
sound,  or  a  bruit  not  unlike  that  heard  over  an  aneurysm  may  be 
heard.  If  the  blood  escapes  externally  it  may  do  so  in  jets,  but 
a  continuous  stream  accentuated  by  coughing,  movements  of  the 
patient,  and  similar  efforts,  is  more  common.  When  the  blood  is 
confined  to  the  pericardium  the  phenomena  are  those  of  compression 
of  the  heart.  The  pulse  is  slow,  irregular  and  feeble,  or  absent,  the 
apex  beat  imperceptible,  the  breathing  hurried  and  superficial,  the 
face  cyanotic,  the  cervical  veins  dilated,  and  the  patient  uncon- 
scious, but  the  senses  return  on  providing  an  exit  for  the  blood. 
There  may  be  a  splashing  sound  disappearing  with  the  filling  of 
the  pericardium,  at  which  time  the  area  of  precordial  dulness  will 
be  vastly  increased  (see  "pericardial  effusion").  Death  after 
several  days  or  weeks  is  usually  the  result  of  sepsis  (pericarditis, 
empyema,  pneumonia,  etc.),  although  secondary  hemorrhage  is 
a  possibility,  and  clot,  but  not  air,  embolism  has  been  reported. 
Spontaneous  recovery  occurs  in  i  per  cent,  of  penetrating  and 
9  per  cent,  of  non-penetrating  wounds.  The  wound  is  repaired 
by  fibrous  tissue,  not  muscle,  hence  the  possiblity  of  subsequent 
aneurysm,  rupture,  and  of  murmurs  from  alterations  of  the  cardiac 
orifices.  Pericardial  adhesions  probably  always  follow  wounds 
of  the  pericardium,  but  cause  symptoms  in  only  a  few  of  the 
cases. 

The  diagnosis  is  not  always  easy.  The  superficial  wound  may 
be  in  the  abdomen  or  back  and  the  general  symptoms,  at  least  in 
the  beginning,  shght.  External  bleeding  may  be  profuse  and 
spurting  from  an  intercostal  or  internal  mammary  artery  and 
absent  in  a  wound  of  the  heart.  The  X-ray  may  show  a  hemoperi- 
cardium,  or  in  the  case  of  a  gunshot  wound  the  projectile  in  the 
heart  or  pericardium.  The  only  safe  procedure  in  doubtful  cases 
presenting  a  wound  in  the  region  of  the  heart  is  to  enlarge  the 
wound,  ascertain  if  it  penetrates  the  chest  wall,  and  if  there  be 


2  74  MANUAL    OF    SURGERY 

symptoms  of  hemorrhage  or  "heart  tamponage,"  to  explore  the 
pericardium  and  the  heart. 

The  treatment  is  suture  of  the  heart.  An  anesthetic  should 
be  employed  unless  the  patient  be  unconscious,  using  intratracheal 
insufflation  if  the  pleural  cavity  has  been  opened.  In  one  case, 
in  which  the  pleura  was  unwounded,  we  were  able  to  expose  the 
heart  extrapleurally.  An  atypical  osteoplastic  flap  with  the  base 
towards  the  sternum,  either  in  the  right  or  left  chest  according  to 
indications,  and  including  as  many  ribs  as  may  be  necessary,  for 
proper  exposure,  usually  from  two  to  four,  will  be  indicated  in  most 
of  the  cases.  The  wound  in  the  pericardium  is  enlarged  and  the 
bleeding  from  the  heart  controlled  by  a  linger,  by  compression  of 
the  heart,  by  dislocating  it  forward,  or  by  pressing  it  against  the 
sternum.  Rehn  says  the  operation  may  be  made  bloodless  by 
compressing  the  venae,  cavae  at  their  junction  with  the  right  auricle, 
between  two  fingers;  in  animals  this  procedure  has  been  continued 
for  ten  minutes  without  permanent  harm  following.  The  sutures 
may  be  of  silk  or  catgut,  introduced  by  means  of  a  curved  intestinal 
needle.  A  continuous  suture  may  be  applied  more  rapidly  than  an 
interrupted  and  presents  fewer  knots  on  the  surface  of  the  heart. 
The  heart  may  be  steadied  by  the  lingers,  by  forceps,  or  by  sling 
sutures.  If  the  heart  ceases  to  beat  it  should  be  sutured  quickly  and 
massage  performed.  After  removing  the  blood  from  the  peri- 
cardium and  pleura,  these  cavities  should  be  closed.  We  have 
sutured  the  heart  in  six  cases,  with  four  recoveries. 

Massage  of  the  heart,  by  compressing  the  ventricles  between 
the  thumb  and  lingers,  60  times  to  the  minute,  has  been  employed 
for  suspended  animation  due  to  anesthetics,  wounds  of  the  heart, 
etc.  the  heart  being  exposed  by  thoracotomy,  or  by  incising  the 
diaphragm  after  opening  the  abdomen  (transdiaphragmatic  route). 
After  laparotomy  the  heart  may  be  manipulated  also  through  the 
diaphragm  without  opening  the  structure  (subdiaphragmatic  route). 
The  thoracic  route  should  be  selected  only  when  a  breach  in  the 
thoracic  wall  already  exists,  e.g.,  in  operations  on  the  heart  and 
lungs;  in  all  other  instances  the  subdiaphragmatic  method  is  easier 
and  safer.  Of  26  cases  in  which  the  massage  was  undertaken  by 
the  thoracic  route,  two  were  successful;  of  14  by  the  transdiaphrag- 
matic route,  one;  of  28  by  the  subdiaphragmatic  route,  13  (Lefevre). 
We  have  tried  the  last  named  method  in  a  few  cases  without  success. 
An  incomplete  form  of  cardiac  massage  may  be  performed  by 
making  rhythmical  pressure  (60  per  minute)  over  the  third,  fourth, 
and  fifth  costal  cartilages  on  the  left  side.     In  all  cases  it  is  important 


VASCULAR   SYSTEM 


/:> 


to   maintain    the    respirations    and    the   bodily    heat    by    artificial 
means. 

Pericarditis  is  caused  by  contusions  or  wounds;  infectious 
diseases,  such  as  pyemia  or  septicemia,  rheumatism,  tuberculosis, 
and  pneumonia;  and  by  the  extension  of  infectious  processes  in 
the  neighborhood  of  the  pericardium.  The  nature  of  the  primary 
infection  determines  the  character  of  the  microorganism  found. 
Primary  pericarditis  is  very  rare. 

The  symptoms  are  often  masked  by  those  of  the  primary  illness 
and  the  condition  is  frequently  overlooked.  There  are  dyspnea, 
cough,  fever,  leukocytosis,  small  weak  pulse,  occasionally  the 
pulsus  paradoxus,  frequently  delirium,  pain  and  tenderness  over 
the  heart,  pain  radiating  down  the  left  arm  or  into  the  epigastrium, 
and  a  friction  sound,  perhaps  with  fremitus,  disappearing  as  the 
sac  fills  with  effusion.  In  pericardial  effusion  the  precordial  dulness 
increases  and  becomes  pear-shaped,  the  precordium  bulges,  the 
cardiac  sounds  become  faint  and  distant,  and  there  may  be  aphonia 
and  dysphagia ;  the  apex  beat  is  above  the  lower  boundary  of  dulness 
or  is  absent;  dulness  in  the  fifth  right  interspace  close  to  the  sternum 
(Rotch's  sign)  may  be  present;  percussion  reveals  flatness  with 
marked  resistance;  an  area  of  dullness  with  bronchial  breathing 
near  the  angle  of  the  left  scapula  (Bamberger's  sign)  may  be  present, 
as  may  also  Eii'art's  sign,  in  which  the  first  rib  is  separated  from  the 
clavicle  so  that  the  former  may  be  palpated  its  entire  length.  The 
effusion  may  sometimes  be  demonstrated  with  the  X-ray.  If  the 
fluid  becomes  purulent,  there  may  be  intermittent  fever  with  edema 
of  the  chest  wall.  Exploratory  puncture  will  confirm  the  diagnosis. 
The  most  common  conditions  for  which  pericardial  effusion  is 
mistaken  are  dilatation  of  the  heart,  pleural  effusion,  and  pneumonia. 
When  the  pain  is  referred  to  the  abdomen,  such  conditions  as 
appendicitis,  perforation  of  the  intestine,  and  acute  gastritis  may 
be  simulated. 

The  treatment,  in  the  absence  of  effusion,  is  medical.  Serous 
effusion,  when  excessive,  demands  aspiration.  Hemorrhagic  effusion 
{hemo pericardium)  arising  immediately  after  a  wound  demands 
exploratory  pericardotomy.  At  a  later  period  tapping  may  suffice, 
although  even  then  pericardotomy  may  be  necessary  to  remove 
clots  if  the  symptoms  persist.  Nontraumatic  hemopericardium, 
excluding  scurvy,  is  generally  due  to  a  fatal  malady  (e.g..  rupture 
of  the  heart,  bursting  of  an  aneurysm,  tuberculosis,  cancer,  Bright 's 
disease),  hence  relief  from  tapping  is  only  temporary.  In  purulent 
effusion  (pyopericardium,  empyema  of  the  pericardium)  pericardotomy 


276  MANUAL    OF    SURGERY 

is  required.  Puncture,  as  in  pleural  empyema,  should  not  be  used, 
except  for  diagnosis,  or  for  palliation  in  cases  too  ill  to  stand  peri- 
cardotomy. 

Paracentesis  Pericardii  (tapping  of  the  pericardium). — The 
diagnosis  of  pericardial  effusion  can  be  assured  only  by  exploratory 
puncture,  which  should  be  made  with  an  ordinary  hypodermic 
syringe.  Large  trocars  are  dangerous.  A  line  needle  may  fail  to 
evacuate  thick  pus,  but  it  will  rarely  fail  to  obtain  enough  for 
diagnostic  purposes.  Although  puncture  of  the  heart  with  a  line 
needle  is  generally  harmless,  death  may  follow,  either  immediately 
from  injury  to  the  coordination  center,  or  later  from  hemoperi- 
cardium.  The  needle  should  be  introduced  in  the  fourth  or  fifth 
left  interspace  close  to  the  edge  of  the  sternum,  so  as  to  avoid  the 
pleura  and  the  internal  mammary  artery  (LeConte).  If  no  fluid 
is  withdrawn,  it  may  be  entered  in  the  fifth  intercostal  space,  two 
inches  from  the  left  border  of  the  sternum.  Never  should  the 
puncture  be  made  at  the  spot  where  friction  is  heard,  or  where  the 
heart  sounds  are  very  distinct.  If  the  fluid  is  serous  or  sanguine- 
ous an  aspirator  should  be  connected  with  the  needle;  if  pus  is 
recovered  pericardotomy  is  mandatory, 

Pericardotomy  (incision  of  the  pericardium)  without  resection  of 
a  costal  cartilage  is  indicated  when  the  patient  is  unable  to  stand  a 
general  anesthetic.  The  tissues  should  be  infiltrated  with  Schleich's 
fluid,  and  an  incision  made  in  the  fourth  or  fifth  intercostal  space, 
beginning  at  a  point  one  inch  from  the  sternal  border  and  extending 
to  a  point  an  inch  within  the  nipple  line.  This  avoids  the  interiial 
mammary  artery,  which  runs  parallel  with,  and  a  half  inch  external 
to,  the  edge  of  the  sternum,  but  may  injure  the  pleura;  the  two  layers 
of  pleura,  however,  are  frequently  adherent  at  this  point  in  pyoperi- 
carditis,  and  the  wound  will  be  of  no  consequence.  The  pericardium 
is  incised  and  a  rubber  drainage  tube  inserted.  When  a  general 
anesthetic  is  employed  a  portion  of  the  fourth  or  fifth  costal  cartilage 
may  be  resected  close  to  the  sternum,  ligating  the  internal  mammary 
vessels  if  necessary.  Roberts  advises  turning  up  a  flap,  consisting 
of  the  fourth  and  fifth  costal  cartilages,  the  soft  tissues  of  the  third 
interspace  being  used  as  a  hinge.  Irrigation  with  salt  solution  may 
be  cautiously  used  for  the  removal  of  clots  or  masses  of  fibrin. 

Cardiolysis  is  a  resection  of  varying  amounts  of  bony  tissue 
(ribs  and  sternum)  in  order  to  unfetter  a  heart  bound  to  the  chest 
wall  by  chronic  mediastinopericarditis,  which  manifests  itself  by 
dyspnea,  ascites,  and  other  symptoms  of  cardiac  insufficiency, 
together  with  systolic  retraction  of  the  intercostal  spaces,  retraction 


VASCULAR    SYSTEM  277 

of  the  lower  lateral  and  lower  posterior  portions  of  the  chest  (Broad- 
bent's  sign),  diastolic  shock  or  rebound,  absence  of  respiratory 
movements  in  the  epigastrium,  pulsus  paradoxus  (Kussmaurs  sign), 
and  diastolic  collapse  of  the  cervical  veins  (Friedreich's  sign).  In 
the  few  cases  in  which  this  operation  has  been  performed  the  results 
have  been  gratifying. 

tht:  veins 

Phlebitis,  or  inflammation  of  a  vein,  may  be  acute  or  chronic. 

Acute  phlebitis  is  caused  by  inflammatory  affections  in-  the 
neighborhood  of  a  vein  (periphlebitis),  injuries,  primary  thrombosis 
(thrombophlebitis),  varix,  and  by  such  constitutional  affections  as 
rheumatism,  gout,  and  the  infectious  fevers.  Post-operative  phlebitis 
is  sometimes  due  to  infection,  but  most  of  the  cases  following  aseptic 
operations  are,  we  think,  to  be  ascribed  to  non-bacterial  changes  in 
the  blood  and  slowing  of  the  circulation,  because  the  operations  most 
likely  to  be  followed  by  thrombophlebitis  are  those  involving  varices, 
those  on  anemic  patients,  especially  hysterectomy  for  bleeding 
fibromyoma,  and  those  necessitating  a  prolonged  stay  in  bed,  e.g., 
abdominal  section,  and  because,  like  thrombosis  from  other  general 
conditions,  the  process  is  usually  located  in  the  left  femoral  and 
iliac  veins,  the  reasons  for  which  are  give  under  "Thrombosis." 
Phlebitis  of  the  lower  extremity  complicates  2  per  cent,  of  all  abdomi- 
nal operations,  30  per  cent,  of  these  following  hysterectomy,  15  per 
cent,  oophorectomy,  10  per  cent,  appendicitis,  and  5  per  cent,  renal 
operations.  Large  emboli  are  detached  in  about  2  per  cent,  of  the 
cases,  and  of  these  about  one-third  are  fatal  Tsee  "Pulmonary 
Embolism''). 

The  pathological  changes  usually  begin  in  the  intima,  because 
it  is  the  first  to  yield  in  contusions  and  is  directly  exposed  to  toxins 
circulating  in  the  blood.  The  endothelial  cells  degenerate  and 
liberate  fibrin  ferment,  and  this  with  the  concomitant  roughening 
of  the  intima  leads  to  thrombosis.  The  fate  of  the  thrombus  has 
been  mentioned  under  "Thrombosis."  The  outer  coats  swell  owing 
to  the  dilatation  of  the  vasa  vasorum  and  the  subsequent  exudation. 
The  inflammatory  exudate  and  the  thrombus  may  be  absorbed  or 
organized  (exudative  phlebitis),  or  undergo  suppuration  {suppurative 
phlebitis).  The  former  is  responsible  for  the  massive  emboli  which 
cause  sudden  death,  the  latter  for  the  small  septic  emboli  which 
cause  metastatic  abscesses  (pyemia).  Phlebitis  may  be  sharply 
localized  to  a  small  segment  of  a  vein,  notablv  in  varix  of  the  leg,  or 


278  MANUAL    OF    SURGERY 

it  may  involve  most  of  the  veins  of  an  extremity,  e.g.,  in  phlegmasia 
alba  dolens.  If  it  begins  in  a  small  vein  it  spreads  in  the  direction 
of  the  blood  current,  if  in  a  large  vein  in  both  directions.  Sometimes, 
however,  it  jumps  from  one  segment  to  another,  particularly  in 
gouty  phlebitis.  Multiple  patches  of  phlebitis  in  various  parts  of 
the  body  may  occur  also  in  rheumatism,  chlorosis,  and  tuberculous 
or  cancerous  cachexia. 

The  symptoms  are  local  and  general.  The  local  symptoms  are 
(a)  those  of  inflammation,  viz.,  pain  and  tenderness  along  the  vein, 
which  may  be  felt  as  a  firm  cord  when  the  vein  is  superficial,  elevation 
of  the  local  temperature  and  redness  when  the  perivascular  tissues 
are  involved,  and  fluctuation  in  the  event  of  suppuration,  and  (b) 
those  of  obstruction  to  the  venous  current,  viz.,  edema  and  passive 
congestion  in  the  region  distal  to  the  thrombus,  and  ultimately 
enlargement  of  the  collateral  veins.  The  small  superficial  veins 
often  become  prominent  at  once,  and  the  skin  may  be  bluish,  glossy, 
and,  because  of  the  swelling,  more  smooth  than  normal.  Occa- 
sionally, particularly  in  septic  cases,  a  line  of  ecchymosis  appears 
along  the  inflamed  vein.  Other  symptoms,  referable  to  disturbance 
of  special  functions,  arise  when  the  visceral  veins  are  afifected.  The 
general  symptoms  vary  from  a  slight  rise  of  temperature  to  the  severer 
forms  of  septicemia.  A  progressive  increase  in  the  pulse  rate,  even 
without  fever  (Mahler's  symptom),  should  make  one  suspect  a 
beginning  phlebitis.  Embolism  causes  sudden  death,  pulmonary 
infarction  (see  "Pulmonary  Embolism"),  or,  in  the  case  of  septic 
emboli,  pyemia. 

The  diagnosis  from  lymphangitis  is  rarely  difficult.  In  lymph- 
angitis there  may  be  several  thin  red  lines,  instead  of  one  broad 
line,  as  in  superficial  phlebitis.  In  the  former  the  edema  is  more 
firm,  local  cyanosis  and  varices  are  absent,  the  lymph  glands  are 
enlarged,  and  no  clot  is  felt  in  the  vein. 

The  prophylaxis  of  post-operative  phlebitis  includes  careful  pre- 
paratory treatment,  especially  of  the  heart  and  lungs  if  they  are 
functionally  impaired;  asepsis,  rigorous  hemostasis,  protection 
from  cold,  and  avoidance  of  rough  manipulation  of  the  tissues  during 
operation;  and  after  operation  attention  to  shock,  the  secretions, 
and  the  bowels,  and  allowing  the  patient  to  resume  the  regular  diet 
and  to  sit  up  as  early  as  possible.  When  a  prolonged  stay  in  bed 
is  necessary  centripetal  massage,  active  movements  of  the  arms 
and  legs,  and  breathing  exercises  may  be  ordered.  If  conditions 
favorable  for  thrombosis  exist,  citric  acid,  30  grains  three  times 
daily,  may  be  given  to  lessen  the  coagulative  tendency  of  the  blood, 


VASCULAR    SYSTEM  279 

or  the  milk  iiia_\'  l)f  (lecaUifu-d  by  adding  to  each  pint  30  grains  of 
citrate  of  sochi  (Wright  and  Knapp). 

The  treatment  of  j^hlebitis  itself  is  attention  to  any  existing 
constitutional  disease,  absolute  rest  in  the  recumbent  posture  to 
lessen  the  force  of  the  circulation  and  prevent  the  detachment  of 
emboli,  elevation  of  the  jKirt,  and  the  application  of  cataplasma 
kaolini,  lead-water  and  laudanum,  or  other  evaporating  lotions,  or 
equal  parts  of  ichthyol,  belladonna,  mercury,  and  lanolin,  which 
should  be  laid  on,  not  rubbed  in,  and  held  in  place  with  a  loose 
bandage.  Tight  bandaging,  inunctions,  and  massage  are  dangerous. 
Sitting  up  is  not  absolutely  safe  until  the  clot  has  become  organized 
or  absorbed  (six  to  eight  weeks),  when  gentle  passive  motions  and 
light  frictions  may  be  employed  to  hasten  absorption  of  the  edema. 
An  elastic  bandage  should  be  worn  for  the  same  purpose.  In  sup- 
purative phlebitis  the  vein  should  be  excised,  or,  if  this  is  not  possible, 
incised  and  disinfected,  and  a  ligature  placed  between  the  area  of 
inflammation  and  the  heart,  in  order  to  prevent  pyemia;  thus  in 
thrombosis  of  the  lateral  sinus  due  to  otitis  media,  the  internal  jugular 
vein  should  be  tied  in  addition  to  the  opening  and  disinfection  of 
the  sinus. 

Chronic  phlebitis,  or  phlebosclerosis,  is  a  condition  similar  to  ar- 
teriosclerosis. The  vein  walls  are  thickened  as  the  result  of  acute 
inflammation,  or  of  overdistention,  e.g.,  in  varicose  veins  or  other 
forms  of  obstruction.  Like  arteriosclerosis  it  may  be  widespread  as 
the  result  of  such  conditions  as  syphilis,  gout,  alcoholism,  etc.  The 
treatment  is  that  of  the  cause. 

Varix  (varicose  veins,  phlebectasia)  is  an  elongated,  permanently 
dilated,  tortuous  vein  w4th  thickened  w^alls.  It  is  most  frequent  in 
the  internal  and  external  saphenous  veins  of  the  leg  (Fig.  in),  and 
it  is  with  such  that  we  shall  deal  at  the  present  time,  other  mani- 
festations of  this  abnormality,  such  as  varicocele  and  hemorrhoids, 
being  discussed  in  other  sections  of  the  book. 

The  causes  of  varix  are,  (i)  weakness  of  the  walls  of  the  veins, 
either  hereditary  or  acquired  (phlebitis);  (2)  retardation  of  the  venous 
circulation',  e.g.,  by  cardiac  or  pulmonary  disease,  prolonged  stand- 
ing, and  obstructions,  such  as  garters,  tumors,  pregnant  or  displaced 
uterus;  (3)  compensatory  dilation,  such  as  occurs  in  the  superficial 
veins  of  the  leg  when  the  deep  veins  are  blocked;  and  (4)  an  abnormal 
opening  between  an  artery  and  vein,  such  as  occurs  in  aneurysmal  varix. 
The  condition  is  frequently  present  in  youth,  but  usually  gives  no 
trouble  until  middle  hfe  is  reached.  Women  are  more  liable  to 
varix  than  men,  owing  to  the  influence  of  pregnancy. 


28o 


MANUAL    OF    SURGERY 


Pathology. — The  dilatation  induces  at  first  hypertrophy  of  the 
tunica  media  and  finally  chronic  inflammatory  changes  with  pro- 


FiG.   III. — Varicose  veins  of  the  lower  extremities.     The  veins  in  the  patient's  left  leg 
and  thigh  were  inflamed  and  filled  with  clot   (thrombophlebitis). 


liferation  of  the  connective-tissue  elements.     The  new  tissue  causes 
the  vessel  walls  to  thicken  and  elongate,  and  the  elongation  even- 


VASCULAR    SYSTEM  28 1 

tuatcs  in  tortuosity.  Owing  to  the  distention  of  the  vein,  and  to  the 
crippling  of  the  valves  by  the  sclerotic  process,  the  latter  structures 
become  incompetent,  and  the  walls  of  the  vein  must  suj)port  a 
column  of  blood  extending  to  the  heart,  and  bear  the  brunt  of  every 
sudden  increase  in  the  intravenous  blood  pressure,  e.g.,  by  coughing, 
straining,  etc.  In  old  cases  periphlebitis,  causing  the  vein  to  adhere 
to  the  environing  tissues,  is  always  present,  and  the  inflammatory 
changes  may  extend  to  the  remaining  structures  of  the  leg.  Lym- 
phangitis seriously  augments  the  edema,  renders  it  firmer  in  charac- 
ter, and  sometimes  leads  to  enormous  hyperplasia  of  the  subcutane- 
ous tissues  (pseudo-elephantiasis).  The  arteries  may  suffer  like  the 
veins  and  even  become  thrombosed.  The  nerves  and  muscles  may 
be  attacked  by  interstitial  inflammation,  and  the  bones  beneath 
ulcers  may  be  the  seat  of  osteoporosis  or  even  caries.  The  skin  is 
thickened,  often  pigmented  owing  to  rupture  of  dilated  vasa  vasor- 
um,  and  frequently  reddend,  eczematous,  or  ulcerated. 

Sjnnptoms.- — Varices  usually  develop  insidiously,  although  in 
acute  obstructive  lesions  and  in  arteriovenous  aneurysm  they  may 
arise  quickly.  Both  legs  are  effected  in  70  per  cent,  of  the  cases,  the 
left  alone  in  20  per  cent.,  the  right  alone  in  10  per  cent.  Even  when 
bilateral,  the  affection  is  generally  more  pronounced  on  the 
left  side,  for  the  same  reasons  that  venous  thrombosis  (q.v.)  is  more 
frequent  on  this  side.  In  an  uncomplicated  case  there  may  be  pain 
in  the  leg  and  sole  of  the  foot,  heaviness  of  the  limb,  and  edema, 
particularly  after  walking  or  standing,  and  sometimes  muscular 
cramps.  When  varices  begin  in  the  deep  veins,  the  usual  point  of 
origin  according  to  some  authors,  these  symptoms  may  be  misin- 
terpreted until  the  superficial  veins  dilate,  when  the  condition  is 
readily  recognized.  The  veins  are  at  first  uniformly  distended,  but 
subsequently  become  fusiform  in  places  or  even  sacculated.  Valvu- 
lar incompetence  may  be  demonstrated  by  striking  the  upper  part 
of  the  vein  with  a  finger  and  palpating  the  fluctuation  wave  thus 
induced  at  a  lower  level,  or  by  noting  the  impulse  transmitted  along 
the  blood  column  when  the  patient  coughs.  Trendelenburg's  test 
is  as  follows:  After  the  patient  Lies  down  and  elevates  the  limb, 
compression  is  applied  to  the  upper  part  of  the  saphenous  vein  and 
the  patient  told  to  stand.  If  the  vein  slowly  distends  from  below 
upward  the  valves  are  competent;  if  it  remains  empty  and,  after  the 
compression  is  removed,  suddenly  fills  from  above  downward  the 
valves  are  incompetent  and  the  circulation  reversed.  Chevrier  says 
that  if,  in  the  Trendelenburg  test,  the  varices  fill  slowly  from  below 
upward  while  compression  is  maintained  on  the  upper  part  of  the 


252  MANUAL    OF    SURGERY 

saphenous  vein,  the  valves  of  the  anastomatic  branches  between  the 
superficial  and  deep  veins  are  normal,  but  that  if  the  varices  distend 
quickly  the  same  valves  are  incompetent;  this  is  the  deep,  or  ascend- 
ing reflux,  in  contradistinction  to  the  superficial,  or  descending  reflux, 
of  Trendelenburg. 

Complications. — Rupture  of  a  deep  varix  in  the  calf  occurs  under 
similar  circumstances,  gives  the  same  symptoms,  and  requires  the 
same  treatment  as  rupture  of  the  plantaris  muscle  (q.  v.) .  Rupture  of 
a  superficial  varix  may  result  from  trauma,  ulceration,  or  simply  from 
coughing  or  straining;  in  the  last  instance  it  usually  occurs  where  the 
vein  is  greatly  thinned  as  the  result  of  a  saccular  dilatation.  The 
bleeding  is  more  profuse  than  under  normal  conditions,  because  of  the 
incompetent  valves  and  the  rigidity  of  the  vein,  which  prevents  its 
collapse;  and  when  the  circulation  is  reversed  the  hemorrhage  is 
more  copious  from  the  upper  end  of  the  vein. 

Thromho phlebitis,  usually  exudative  and  localized  to  a  segment  of 
the  vein,  is  a  frequent  complication,  owing  to  the  sluggish  circulation 
and  the  alterations  in  the  walls  of  the  vein,  and  one  which  may  result 
in  obliteration  of  the  vessel  and  spontaneous  recovery.  Embolism 
is  not  as  menacing  as  in  a  non-varicosed  vein,  thanks  to  the  frequency 
of  reversal  of  the  circulation. 

Ulceration,  the  type  of  which  has  been  described  in  chapter  viii,  is 
the  most  frequent  complication.  It  may  follow  the  rupture  of  a 
superficial  varix  or  a  perivenous  abscess,  or  start  in  a  scratch,  area  of 
eczema,  or  minute  spot  of  necrosis.  The  last  is  due  to  capillary 
thrombosis  consequent  upon  the  blood  pressure  in  the  veins  equaliz- 
ing that  in  the  arteries. 

Eczema  and  kindred  dermatoses,  lymphangitis,  and  inflammatory 
changes  in  the  other  tissues  of  the  leg  have  been  mentioned  in  the 
paragraph  on  the  pathology. 

The  treatment  may  be  palliative  or  radical.  Palliative  treatment 
consists  in  removal  of  circular  garters,  and  all  forms  of  dress  which 
constrict  the  abdomen,  gentle  massage  if  the  skin  is  healthy,  attention 
to  constipation  and  any  existing  cardiac  or  pulmonary  affection, 
and  the  application  of  an  elastic  stocking  or  bandage.  The  bandage 
should  be  taken  oft"  at  bedtime  and  the  skin  rubbed  with  alcohol; 
after  the  morning  bath  the  limb  should  be  powdered  with  stearate  of 
zinc  and  the  bandage  reapplied. 

The  radical  treatment,  or  operation,  is  followed  by  the  best  results 
in  a  unilateral  circumscribed  varicosity.  In  addition  to  these  cases, 
operation  is  indicated  when  there  are  thin-walled  diverticula  which 
threaten  to  burst;  when  ulcers  or  eczema  refuse  to  heal;  when  there  is 


VASCULAR    SYSTEM  283 

great  pain;  when  thrombosis  occurs;  when  portions  of  the  vurix  are 
situated  over  the  crest  of  the  tibia,  where  as  the  result  of  injury  they 
may  rupture  or  become  inflamed;  and  when  the  valves  are  incompe- 
tent as  shown  by  the  tests  already  described.  Excluding  the  general 
condition  of  the  patient,  operation  is  contraindicated  when  the 
varicosity  is  compensatory  to  thrombosis  of  the  deep  veins,  as  this 
would  lead  to  permanent  edema.  In  many  of  these  cases  elastic  com- 
pression also  increases  the  circulatory  difficulties.  Excision  of  a 
circumscribed  varix  is  performed  by  incising  the  skin,  ligating  the 
vein  or  veins  above  and  below  with  catgut,  and  removing  the  varix. 
Total  saphenectomy  necessitates  an  incision  extending  from  the 
saphenous  opening  to  the  ankle,  or  better,  a  succession  of  incisions, 
the  vein  being  enucleated  beneath  the  skin  lying  between  thye  cuts. 
Instead  of  using  the  finger  for  enucleation  Mayo  threads  the  vein 
on  a  ring  which  is  attached  to  a  handle  and  pushed  along  the  vein 
beneath  the  skin.  Babcock  employs  a  long  pliable  probe,  with  an 
acorn  tip  at  each  end,  one  larger  than  the  other.  After  tying  one 
extremity  of  the  section  of  vein  to  be  removed,  the  small  end  of  the 
varix  extractor  is  pushed  along  within  the  vein  as  far  as  possible,  at 
which  point  the  vein  is  exposed  by  an  incision,  clamped  below  the 
end  of  the  probe,  then  opened,  so  that  the  probe  may  be  drawn  out. 
The  other  end  of  the  venous  segment  is  then  tied  beneath  the  larger 
acorn  which  is  cuffed  to  catch  the  vein,  and  the  vein  is  extracted  from 
beneath  the  skin  by  pulling  on  the  smaller  end  of  the  probe.  Mar- 
mourian  passes  a  probe,  eye  first,  through  the  vein  between  the  cu- 
taneous incisions,  fixes  the  vein  to  the  eye  of  the  probe  with  sutures, 
and  extracts  the  vein,  at  the  same  time  turning  it  outside  in,  by  pull- 
ing on  the  probe.  These  ingenious  methods  for  assisting  saphenec- 
tomy are  of  the  most  value  in  the  thigh;  below  the  knee  the  veins  are 
often  so  convoluted  that  an  instrument  cannot  be  passed  along  them, 
and  the  varices  are  often  so  intimately  adherent  to  the  skin  that 
subcutaneous  enucleation  is  impossible  and  a  section  of  the  skin  must 
be  removed  with  the  veins.  Trendelenburg  breaks  the  long  column 
of  blood  which  the  veins  of  the  leg  must  support  by  incising  about 
four  inches  of  the  internal  saphenous  vien  at  the  juncture  of  the 
middle  and  lower  thirds  of  the  thigh.  The  latest  statistics  for  this 
operation  (Goerlich)  show  that  79  per  cent,  were  symptomatically 
cured  or  vastly  improved,  although  the  varicosities  recurred  in 
about  half  the  cases.  Phelps  uses  multiple  ligatures  (thirty  or 
forty).  Schede  encircles  the  leg  with  an  incision  at  the  junction  of 
the  upper  and  middle  thirds,  ties  all  visible  veins,  and  sutures  the 
wound.     Friedel  makes  a  long  spiral  incision,  encircling  the  leg  a 


284  MANUAL    OF    SURGERY 

number  of  times,  from  the  foot  to  the  knee,  and  ties  all  of  the  exposed 
veins.  Cecca  aims  to  support  the  saphenous  vein  by  suturing  the 
deep  fascia  over  it.  Katzenstein  sews  the  margins  of  the  sartorius 
together  over  the  vein,  thus  providing  it  with  a  muscular  canal  that, 
by  its  intermittent  contractions,  urges  the  blood  along  the  vein. 
Delbet  suggests,  in  cases  of  valvular  insufficiency,  ligating  the  internal 
saphenous  12  cm.  below  the  saphenous  opening  and  anastomosing 
the  distal  end  with  the  femoral  vein  (end-to-side),  thus  permitting 
the  blood  to  flow  into  the  femoral  below  competent  valves,  of  which 
there  is  always  at  least  one  pair  between  the  original  and  the  new 
site  of  anastomosis. 

The  choice  of  operation,  in  small  varices,  is  excision  of  the  varix. 
When  the  veins  are  extensively  involved  the  patient  should  wear  an 
elastic  bandage  or  stocking  for  several  days;  if  this  increases  the 
trouble  there  is  probably  thrombosis  of  the  deeper  veins  and  opera- 
tion is  contraindicated,  unless  the  veins  are  enormous,  in  which 
event  it  might  be  advisable  to  support  the  vessels  by  the  Cecca  or  the 
Katzenstein  operation.  If  the  varix  is  not  compensatory  and  there 
is  a  descending  without  an  ascending  reflux  the  Trendelenburg  opera- 
tion may  be  performed;  in  all  other  cases  it  is  contraindicated.  If 
there  is  only  an  ascending  reflux,  circumscribed  excision  of  the  varices, 
which  necessitates  ligation  of  the  deep  anastomotic  branches,  is  the 
best  operation.  If  there  is  both  a  descending  and  an  ascending 
reflux  the  only  procedure  of  value  is  total  saphenectomy.  This  is 
effective  also  when  there  is  only  a  descending  or  only  an  ascending 
reflux,  but  which,  because  of  its  magnitude,  it  should  be  reserved  for 
the  cases  in  which  the  less  extensive  operations  are  impotent. 

Venesection  (phlebotomy),  or  the  opening  of  a  vein  to  abstract 
blood,  has  two  principal  indications,  (i)  to  relieve  overdistention  of 
the  right  heart  from  any  cause,  and  (2)  to  diminish  the  amount  of 
toxins  in  the  body  in  conditions  like  uremia.  In  the  latter  instance 
bleeding  is  generally  followed  by  the  intravenous  injection  of  salt 
solution.  The  operation  is  usually  performed  at  the  bend  of  the 
elbow  upon  the  median  basilic  vein,  which  is  larger  and  more  distinct 
than  the  median  cephalic,  but  has  the  disadvantage  of  lying  directly 
over  the  brachial  arter}-,  which  may  be  wounded  if  the  knife  is  thrust 
too  deeply.  A  bandage  is  tied  around  the  arm  above  the  elbow, 
just  tight  enough  to  arrest  the  venous  return  without  interfering 
with  the  arterial  supply.  The  patient  grasps  a  bandage  or  makes  a 
hard  fist  so  as  to  press  the  blood  from  the  muscles  into  the  superficial 
veins.  The  vein  is  steadied  with  the  left  hand,  and  opened  with  the 
right  hand  by  an  oblique  incision.     The  blood  is  collected  in  a 


VASCULAR   SYSTEM  285 

graduated  receptacle  until  a  sufficient  quantity  has  been  withdrawn, 
when  a  finger  is  placed  over  the  bleeding  point,  the  bandage  above  the 
elbow  removed,  and  a  sterile  gauze  pad  bandaged  over  the  wound. 

Transfusion  of  blood  has  proved  of  value  in  acute  hemorrhage 
and  in  pathological  hemorrhage,  in  pure  shock  its  remedial  effects 
are  questionable  and  in  blood  diseases  and  toxemias  it  seems  of 
little  use.  In  other  words,  transplanted  blood  constitutes  a  fluid  for 
the  heart  and  the  arteries  to  act  upon,  is  an  efficient  hemostatic,  but 
that  it  has  a  hematopoietic,  antibacterial,  or  antitoxic  effect  has  not 
been  proved;  the  nourishment  it  contains  should  be  temporarily  bene- 
ficent. Before  transfusion  the  donor's  blood  should  be  subjected  to 
the  Wasserman  test  for  syphilis,  and  as  there  is  some  danger  of 
hemolysis  and  agglutination  the  effect  of  the  patient's  blood  upon 
that  of  the  donor  should  be  studied.  According  to  Mossall  individuals 
may  be  divided  into  four  blood  groups,  (i)  The  serum  of  those  in 
this  group  does  not  agglutinate  the  corpuscles  of  any  other  group. 
The  corpuscles  of  group  i  are  agglutinated  by  the  serum  of  group  2, 
3,  and  4.  (2)  The  serum  of  group  2  agglutinates  the  corpuscles  of 
groups  I  and  3.  The  corpuscles  of  group  2  are  agglutinated  by  the 
serum  of  groups  3  and  4.  (3)  The  serum  of  group  3  agglutinates 
the  corpuscles  of  groups  i  and  2.  The  corpuscles  of  group  3  are 
agglutinated  by  the  serum  of  groups  2  and  4.  (4)  The  serum  of 
group  4  agglutinates  the  corpuscles  of  groups  i,  2,  and  3.  The 
corpuscles  of  group  4  are  not  agglutinated  by  any  serum.  Eight 
per  cent,  of  all  individuals  are  in  group  i,  40  per  cent,  in  group  2, 
10  per  cent,  in  group  3,  and  42  per  cent,  in  group  4.  If  possible  the 
donor  and  the  patient  should  be  in  the  same  group,  although  if  the 
donor's  blood  contains  an  agglutinin  for  the  patient's  corpuscles, 
this  agglutinin  will  be  rapidly  diluted  and  no  harm  may  follow.  If 
the  patient's  serum  agglutinates  the  corpuscles  of  the  proposed  donor, 
another  person  willing  to  contribute  blood  must  be  sought.  It  will 
thus  be  seen  that  a  patient  in  group  i  is  a  ''universal  recipient."  and 
that  a  person  in  group  4  is  a  '"universal  donor.''  If.  owing  to  lack 
of  facilities  or  time,  these  tests  cannot  be  made,  intravenous  infusion 
of  salt  solution  should  be  employed.  Transfusion  may,  of  course, 
be  performed  later  if  such  seems  to  be  indicated.  There  are  two 
methods,  the  direct,  in  which  the  blood  is  conveyed  directly  from  the 
vessels  of  one  individual  into  those  of  another,  and  the  indirect,  in 
which  the  blood  of  one  individual  is  first  drawn  into  a  receptacle 
before  it  is  injected  into  the  vessels  of  the  second  individual. 

Direct  transfusion  may  be  performed  by  anastomosing  the  radial 
artery  of  one  individual  with   any  convenient  superficial  vein  of 


286 


MANUAL    OF    SURGERY 


another.  Under  local  anesthesia  both  artery  and  vein  are  exposed, 
tied  below,  and  secured  with  an  arterial  clamp  above.  Each  is  then 
cut  above  the  hgature  and  the  adventitia  of  the  central  end  pulled 
down  and  snipped  off  with  scissors.  The  vessels  may  then  be  united 
by  the  Carrel  method,  or  by  glass  or  metal  tubes.  The  clamps 
are  then  removed  and  the  anastomosis  covered  with  a  hot  moist 
sponge,  to  relax  the  artery.  The  time  the  blood  is  allowed  to  flow 
depends  upon  the  effects  noted,  but  is  usually  from  20  to  40  minutes. 
In  order  to  prevent  acute  dilatation  of  the  heart,  which  sometimes 
follows  the  rapid  introduction  of  a  large  quantity  of  blood  into  the 
circulation,  Dorrance  and  Ginsburg  suggest  vein-to-vein  instead  of 
artery-to-vein  transfusion.  As  the  veins  are 
larger  than  the  arteries,  veno-venous  is  much 
easier  to  perform  than  arteriovenous  anasto- 
mosis, but,  owing  to  the  composition  of  venous 
blood,  the  chances  of  thrombosis  are  probably 
greater.  Because  of  its  technical  difffculties 
and  the  impossibility  of  measuring  the  amount 
of  blood  transfused,  the  direct  has  been  super- 
ceded by  the  indirect  method  of  transfusion. 

In  performing  indirect  transfusion  Kimpton 
uses  a  number  of  glass  cyhnders  (Fig.  112),  the 
inner  surfaces  of  which  are  coated  with  stearin, 
paraflEin,  and  vaselin,  in  the  proportion  of  1-2-2, 
after  the  cylinders  have  been  heated  over  a 
Bunsen  burner  and  the  paraffin  mixture  hquefied 
Fig.  112.— The  glass    ^y  placing  the  jar  in  which  it  is  kept  in  a  basin 

cylinder,      of     whatever  .  .       .  j      - 

capacity  desired,  is  closed  of  hot  water.     A  prominent  vein  IS  exposed  at 

above  by  a  cork.     Below     ^^     ^   ^  ^f  ^^^^  gH^^^^.  ^f  ^  j^^  ^^j^^j.  ^^  j  recipient 
the  upper   end  is  a  side  _  ■' 

tube.    The  lower  end  is    and  two  ligaturcs  placed  under  each  vein.     A 

fashioned  into  a  cannula.  .  .        .  i    ^i         j  j 

tourniquet  is  drawn  around  the  donor  s  arm 
just  tight  enough  to  produce  congestion,  and  the  proximal  ligature 
tied.  The  distal  ligature,  untied,  serves,  when  drawn  upon,  to  close 
the  vein.  A  slit  is  made  in  the  donor's  vein  between  the  hgatures, 
and  the  cannula  inserted  toward  the  hand.  In  the  course  of  two  or 
three  minutes  the  cylinder  is  full  of  blood,  during  which  time  the 
vein  of  the  recipient  is  tied  distally,  and  opened,  the  proximal  liga- 
ture being  employed  in  the  same  manner  as  the  distal  ligature  on 
the  vein  of  the  donor.  The  cannula  of  the  full  cylinder  is  now  in- 
serted into  the  vein  of  the  recipient,  care  being  taken  during  the 
transference  to  place  the  thumb  over  the  side  tube,  and  to  keep  the 
side  tube  uppermost  and  on  the  same  level  as  the  cannula.     The 


VASCULAR    SYSTEM  287 

cylinder  is  held  uj)riji;ht  and,  with  the  aid  of  a  rubber  bulb  which  is 
attached  to  the  side  tube,  emptied.  The  cannula  is  withdrawn 
while  still  tilled  with  blood.  As  many  cylinders  as  may  be  needed 
are  tilled  and  emptied,  using  the  same  veins. 

The  sodium  citrate  method  (Lewisohn)  is  the  one  usually  employed. 
Chemically  pure  sodium  citrate  added  to  freshly  distilled  sterile 
water  is  boiled  for  two  minutes,  or  put  in  papers  and  sterilized  dry 
for  30  minutes,  at  248  degrees  F.  Nine  grs.  of  sodium  citrate  in 
I  ounce  of  water  makes  approximately  a  2  per  cent,  solution, 
and  this  solution  is  used  in  the  proportion  of  i  part  to  9 
parts  of  blood,  thus  making  a  0.2  per  cent,  solution  of  citrated 
blood.  A  tourniquet  is  applied  to  the  donor's  arm,  and  the  median 
basilic  or  the  median  cephalic  vein  punctured  with  a  large  calibred 
needle,  or  exposed  by  an  incision  and  a  cannula  inserted.  The  blood 
is  collected  in  a  graduated  glass  receptacle,  containing  the  citrate 
solution,  with  which  it  is  mixed  by  stirring  gently  with  a  glass  rod. 
If  450  c.c.  of  blood  are  to  be  given,  the  receptacle  should  contain  50 
c.c.  of  the  two  per  cent,  citrate  solution.  As  clotting  sometimes 
occurs  with  this  mixture  many  surgeons  use  30  c.c.  of  the  2  per  cent, 
citrate  solution,  larger  amounts  of  blood  being  treated  proportion- 
ately. The  blood  is  introduced  into  the  patient's  vein  in  the  same 
manner  as  salt  solution  (vide  infra). 

In  addition  to  clot  embolism,  hemolysis,  agglutination,  and  acute 
dilatation  of  the  heart,  the  possible  dangers  of  transfusion  are  infec- 
tion from  faulty  technic,  a  danger  common  to  all  operations;  recur- 
rent bleeding,  if  the  transfusion  is  performed  for  post-hemorrhagic 
anemia  and  the  source  of  the  bleeding  has  not  been  controlled;  and 
transmission  of  disease  from  one  individual  to  another,  which  can 
be  avoided,  at  least  in  one  direction,  by  selecting  a  healthy  donor. 
The  danger  signs  during  transfusion  are  cough,  dyspnea,  cyanosis,  car- 
diac oppression,  syncope,  marked  slowing  or  great  rapidity  of  the 
pulse,  and  violent  pains  throughout  the  body,  especially  in  the  lumbar 
region.  If  any  of  these  symptoms  of  incompatibility  appear  the 
transfusion  should  be  stopped  and  a  new  donor  obtained.  After 
transfusion  from  15  to  20  per  cent,  of  the  patients  have  a  chill,  fol- 
lowed by  fever,  urticaria,  erythema,  or  a  similar  eruption. 

Intravenous  infusion  of  salt  solution,  the  preparation  of  which  is 
given  under  "Technic,"  finds  its  chief  indication  after  severe  hemor- 
rhages, but  is  used  also  in  shock,  in  toxemic  conditions,  after  vene- 
section, in  order  to  "wash  the  blood,"  and  as  a  diuretic  when  little 
or  no  urine  is  being  secreted.  The  infusion  apparatus  consists  of  a 
graduated   reservoir   connected   with   a   blunt   beveled   cannula   by 


255  MANUAL    OF    SURGERY 

means  of  a  rubber  tube.  In  an  emergency  a  fountain  syringe,  or  an 
ordinary  funnel,  and  an  aspirating  needle  may  be  employed.  The 
entire  apparatus  should  be  sterilized  by  boiling,  or  if  sterilized  by 
chemical  means,  all  traces  of  the  antiseptic  should  be  removed 
by  flushing  with  normal  salt  solution  before  use.  The  fluid  may  be 
injected  into  any  vein  of  sufficient  calibre,  but  the  median  basilic  or 
the  internal  saphenous  is  usually  the  most  convenient.  A  bandage  is 
tied  around  the  limb  in  order  to  make  the  veins  prominent,  and  the 
vein  exposed  by  an  incision  and  two  Hgatures  of  catgut  passed 
beneath  it.  One  ligature  is  pulled  into  the  lower  angle  of  the  wound 
and  tied.  The  vein  is  then  opened  by  a  transverse  incision,  and  the 
cannula  inserted  after  some  of  the  solution  has  been  allowed  to  flow 
through  it  in  order  to  exclude  air.  The  upper  hgature  should  be 
tied  about  the  cannula  by  the  first  half  of  a  surgeon's  knot,  so  that  at 
the  completion  of  the  operation  it  may  be  tightened  and  secured  by  a 
second  turn  after  the  cannula  has  been  withdrawn.  The  temperature 
of  the  fluid  should  be  iio°  F.  in  the  reservoir,  as  it  loses  some  heat 
before  entering  the  vein.  The  amount  injected  will  usually  be  one 
pint.  If  the  cannula  is  in  the  vein,  and  the  bandage  around  the  hmb 
has  been  removed,  the  fluid  flows  readily  with  the  reservoir  elevated 
several  feet  and  no  pumping  apparatus  is  necessary.  At  the  comple- 
tion of  the  operation,  the  wound  is  sutured  and  a  sterile  dressing 
applied.  Intravenous  infusion  may  be  accomplished  also  by  plunging 
a  fine  hollow  needle  through  the  skin,  directly  into  a  vein  that  has 
been  made  prominent  by  compression.  Kuettner  suggests  introduc- 
ing oxygen  with  the  salt  solution.  "A  reservoir  is  filled  with  looo  c.c. 
of  salt  solution,  and  oxygen  allowed  to  flow  in  from  a  tank  until  loo  c.c. 
of  the  solution  is  displaced.  The  reservoir  is  then  closed  and  shaken 
until  the  oxygen  is  absorbed  by  the  solution."  The  dangers  of  intra- 
venous infusion,  excluding  air  embolism  and  infection,  which  can  be 
prevented  by  proper  technic,  are  hemolysis  if  the  solution  is  hypoto- 
nic, salt  poisoning  if  the  solution  is  hypertonic  (vide  infra),  poisoning 
from  the  products  of  dead  organisms  if  stale  water  is  used  to  make 
the  solution,  acute  dilatation  of  the  heart  and  edema  of  the  lungs  and 
brain  if  too  much  solution  is  introduced,  and  recurrence  of  bleeding 
if  all  wounded  vessels  have  not  been  secured.  The  chill  which 
sometimes  follows  intravenous  infusion  is  apparently  harmless. 

Hypodermoclysis,  or  the  subcutaneous  injection  of  salt  solution, 
and  enteroclysis,  in  which  water  is  introduced  into  the  rectum,  may 
be  used  to  substitute  or  supplement  infusion  when  time  is  not  an 
element  of  great  importance.  Hypodermoclysis  is  performed  with  the 
same  precautions  as  intravenous  infusion,  by  introducing  an  aspira- 


VASCULAR    SYSTEM  289 

tor  needle  into  the  loose  connective  tissue  of  the  buttock,  back, 
ab(lt)nien,  or  axilla.  'I'he  needle  is  connected  with  a  reservoir  by 
means  of  a  rubber  tube,  and  the  reservoir  held  several  feet  above 
the  point  of  insertion  of  the  needle,  so  that  the  lluifl  is  slowly  forced 
into  the  tissues,  forming  a  swelling  which  gradually  subsides  as  the 
fluid  is  absorbed.  If  more  than  a  pint  is  injected,  the  needle  should 
be  introduced  in  another  situation;  or,  in  order  to  save  time,  two 
needles,  each  connected  with  one  limb  of  a  Y-shaped  tube  may  be 
employed.  Occasionally  suppuration  or  sloughing  follows,  particu- 
larly in  septic  cases.  Enteroclysis  must  never  be  performed  quickly, 
otherwise  the  fluid  will  be  rejected.  Eight  fluid  ounces  of  water  may 
be  given  every  three  or  four  hours,  in  a  slow  trickle,  so  that  from  20 
to  30  minutes  will  be  consumed  during  the  injection;  or  the  con- 
tinuous method  may  be  adopted,  as  described  in  the  section  on  the 
"Treatment  of  Peritonitis."  We  prefer  the  intermittent  plan,  as  it 
is  less  disgreeable  to  the  patient,  and  never  use  salt  solution.  Salt 
solution  when  introduced  in  enormous  quantities  is  not  entirely  free 
from  danger.  As  much  as  48  pints,  which  contains  six  ounces  of 
salt,  has  been  given  in  one  day,  and  this  is  too  much,  especially  in 
view  of  the  case  recently  reported  by  Brooks,  in  which,  after  a  simple 
appendectomy,  death  followed  the  injection  of  an  enema  containing 
9  ounces  of  salt,  a  strong  stock  solution  having  been  carelessly 
substituted  by  a  nurse  for  the  physiologic  solution.  A  somewhat 
similar  case  is  reported  by  Campbell:  A  mother  ignorantly  gave  her 
child  an  enema  containing  a  pound  of  salt,  this  was  followed  promptly 
by  thirst,  fever,  purging,  convulsions,  and  death. 

Contusions  of  veins  may  result  in  Assuring  of  the  intima  and 
thrombophlebitis,  particularly  if  the  vein  is  diseased,  as  in  varix. 
The  symptoms  and  treatment  of  thrombosis  from  injury  are  those  of 
phlebitis.  Sloughing  of  the  vein  and  secondary  hemorrhage  are 
most  frequent  after  infected  gunshot  wounds. 

Wounds  of  veins  are  classified  like  wounds  of  arteries.  The 
symptoms  and  treatment  are  given  in  the  section  on  "Hemorrhage." 
The  dangers  are  severe  or  fatal  primary  hemorrhage,  air  embolism, 
clot  embolism  (which  if  septic  will  lead  to  pyemia),  phlebitis,  edema, 
gangrene,  and  secondary  hemorrhage. 

Free  venous  transplantation  (usually  the  internal  saphenous  or 
the  external  jugular)  has  been  employed  13  times  to  replace  a  seg- 
ment of  an  artery  (popliteal,  femoral,  external  iliac,  axillary,  brachial) 
removed  for  aneurysm  or  tumor,  with  eight  successful  results,  and 
once  with  success  to  reestablish  the  continuity  of  a  vein  (Moure). 
Segments  of  a  vein  have  been  used  also  to  drain  the  lateral  ventricle 

19 


290  MANUAL   OF    SURGERY 

in  hydrocephalus,  and  the  peritoneal  cavity  in  ascities,  to  act  as  a 
conduit  between  the  ends  of  a  severed  nerve,  to  prevent  adhesions 
after  neurorrhaphy  and  tenorrhaphy,  to  reinforce  the  suture  line 
after  urethrorrhaphy.  Attempts  to  restore  the  urethra,  the  ureter, 
and  the  common  bile  duct  by  a  free  venous  graft  have  failed,  although 
the  urethra  and  Steno's  duct  (q.v.)  have  been  repaired  by  a  pedun- 
culated venous  graft. 

I 

THE  ARTERIES 

Arteritis,  or  inflammation  of  an  artery,  may  be  acute  or  chronic. 
Anatomically,  it  may  be  divided  into  periarteritis,  mesarteritis,  and 
endarteritis,  but  as  all  three  coats  are  usually  more  or  less  affected  at 
the  same  time,  this  classification  is  of  little  value. 

Acute  arteritis  may  be  suppurative  (necrotic)  or  productive 
(plastic).  Acute  suppurative  arteritis  results  from  suppurative 
lesions  in  the  neighboring  tissues,  or  from  an  infected  embolus.  In 
the  smaller  vessels  the  process  usually  leads  to  thrombosis,  in  the 
larger  arteries  the  walls  may  give  way  and  serious  hemorrhage 
result.  Secondary  hemorrhage  is  practically  always  due  to  this  cause. 
An  acute  infectious  endarteritis  resembling  malignant  endocarditis, 
with  which  it  is  usually  associated,  has  been  described.  Acute 
productive,  or  plastic  arteritis,  occurs  as  the  result  of  injury  or  the 
lodgment  of  an  embolus,  in  the  absence  of  infection.  It  is  nature's 
method  of  closing  vessels  after  ligation,  torsion,  and  wounds.  The 
vasa  vasorum  dilate,  exudation  occurs,  the  intima  prohferates,  and 
the  clot  becomes  organized,  the  new  connective  tissue  obliterating 
the  lumen  of  the  vessel  (see  "Arrest  of  Hemorrhage")-  Acute 
arteritis,  manifested  by  pain,  tenderness,  and  occasionally  redness 
and  swelling  along  the  course  of  an  artery,  particularly  of  the  lower 
limb,  may  occur  during  the  course  of,  or  just  subsequent  to, 
the  infectious  fevers.  In  these  cases  thrombosis  and  gangrene  may 
develop.  The  treatment  of  acute  arteritis  occurring  in  the  course  of 
infectious  fevers  is  that  of  phlebitis.  The  treatment  of  threatened 
gangrene  from  arteriothrombosis  has  already  been  discussed.  Acute 
suppurative  arteritis  is  seldom  suspected  until  the  occurence  of 
secondary  hemorrhage. 

Chronic  arteritis  {arteriosclerosis,  chronic  endarteritis,  atheroma) 
is  a  chronic  inflammatory  and  degenerative  process  of  the  arterial 
walls.  The  disease  may  involve  the  capillaries  as  well  as  the 
arteries  (arteriocapillary  fibrosis)  and  may  invade  even  the  veins 
{angio  sclera  sis). 


VASCULAR    SYTSEM  29I 

The  causes  of  arteriosclerosis  are  old  age,  and  chronic  intoxica- 
tions, amonj^^  which  may  be  mentioned  syphilis,  gout,  alcoholism, 
lead  poisoning,  nephritis,  rheumatism,  and  diabetes.  The  increased 
blood  pressure  incident  to  habitual  overeating  and  muscular 
overwork  is  said  to  be  of  etiologic  importance  and  the  disease  is 
sometimes  found  after  acute  infections,  such  as  scarlet  fever,  typhoid 
fever,  and  influenza. 

Arteriosclerosis  may  be  circumscribed  or  diffuse.  In  the  former, 
commonly  seen  in  the  large  vessels,  particularly  the  aorta,  the  deeper 
layers  of  the  intima  prohferate  and  give  rise  to  more  or  less  nodular 
patches,  which  may  become  fibrous,  calcified  {atheromatous  plate) ,  or 
fatty;  in  the  last  event  a  cheesy  mass  may  be  formed  {atheromatous 
abscess),  which  on  discharging  leaves  a  necrotic  patch  {atheromatous 
ulcer).  The  middle  coat  of  the  artery  is  invaded  by  the  disease 
and  the  outer  coat  is  thickened.  Diffuse  arteriosclerosis  more  com- 
monly attacks  the  small  vessels.  The  entire  arterial  wall  becomes 
thickened,  and  the  internal  coat  undergoes  fatty  degeneration  {athe- 
roma) and  may  subsequently  become  calcified. 

Arteriosclerosis  is  recognized  by  increased  arterial  tension,  hyper- 
trophy of  the  heart,  accentuation  of  the  aortic  second  sound,  and  by 
feeling  the  superficial  arteries,  which  are  found  to  be  thickened, 
rigid,  or  even  calcified.  Calcareous  arteries  can  be  demonstrated 
by  the  X-ray. 

Although  the  treatment  belongs  to  the  physician,  the  surgical 
relations  of  arteriosclerosis  should  not  be  overlooked.  Chronic 
arteritis  results  (i)  in  dilatation  or  rupture  when  the  degenerative 
changes  in  the  musculoelastic  median  coat  predominate;  (2)  in 
narrowing  or  obliteration  when  the  proliferation  of  the  subendothelial 
layer  is  in  excess  {endarteritis  obliterans);  or  (3)  simply  in  loss  of 
elasticity,  without  alteration  of  the  lumen,  when  these  changes  are 
equalized. 

I.  Aneurysm  is  most  frequently  due  to  syphilitic  arteritis. 
Syphilitic  arteritis  attacks  a  series  of  vessels,  a  single  vessel,  or  a 
segment  of  a  vessel,  and  is  sometimes  bilateral;  the  middle  coat  is 
most  afTected,  being  invaded  with  round  cells,  and  its  fibers  degen- 
erated, atrophied,  or  fragmented;  rupture  may  follow,  as  in  apo- 
plexy, or,  if  only  the  middle  coat  gives  way,  a  scar  results,  which  may 
subsequently  yield  and  form  an  aneurysm;  the  latter  applies  par- 
ticularly to  large  arteries;  the  tendency  in  small  vessels  is  towards 
obliteration.  The  possibility  of  arterial  rupture  should  be  kept  in 
mind  when  attempts  are  made  to  reduce  an  old  dislocation  or  to 
straighten  a  contracted  joint,  in  an  individual  with  atheroma. 


292  MANUAL    OF    SURGERY 

2.  Narrowing  of  the  arteries  may  be  responsible  for  many  nutri- 
tional disturbances,  among  which  may  be  mentioned,  as  of  surgical 
interest,  neuralgia,  pancreatitis,  gastric  and  intestinal  ulceration, 
arteriosclerotic  coHc,  intermittent  claudication,  and  gangrene. 
Arteriosclerotic  colic  may  simulate  gallstones,  appendicitis,  and  other 
abdominal  affections.  In  advanced  arteriosclerosis  wounds  are 
often  slow  in  healing,  and  in  these  cases  only  urgent  operations  should 
be  performed.  Even  a  trivial  operation  on  the  toe  may  inaugurate 
gangrene,  and  after  enterorrhaphy  necrosis  of  the  margins  of  the 
incision  and  fecal  fistula  are  of  frequent  occurrence.  Primary 
hemorrhage  from  a  narrowed  artery  is  comparatively  slight,  but, 
owing  to  the  danger  of  cutting  through  of  the  ligature,  secondary 
hemorrhage  is  relatively  frequent.  Diseased  arteries  are  predis- 
posed to  thrombosis  from  injury,  hence  the  danger  of  the  Esmarch 
band,  of  Bier's  treatment,  and  of  tight  bandages  in  those  with 
arteriosclerosis. 

3.  Loss  of  elasticity  in  collateral  arteries  accounts  for  many  of  the 
bad  results  after  ligation,  thrombosis,  and  the  impaction  of  an 
embolus.  Diseased  arteries  may  supply  a  part  with  adequate 
nourishment  when  it  is  at  rest  but  fail  to  dilate  in  response  to  in- 
creased activity,  thus  lack  of  elasticity  in  the  cerebral  vessels  may 
cause  transient  paralysis,  in  the  cardiac  vessels  angina  pectoris, 
in  the  abdominal  vessels  arteriosclerotic  colic,  and  in  the  arteries  of 
the  leg  intermittent  claudication.  The  last  manifests  itself  as 
attacks  of  pain  and  weakness,  especially  in  the  calf,  and  is  a  prodro- 
mal symptom  of  gangrene. 

Injuries  of  arteries  may  be  contusions  or  wounds. 

Contusion  of  an  artery  varies  in  its  results  according  to  the 
violence  of  the  injury  and  the  state  of  the  arterial  walls.  Normal 
arteries,  owing  to  their  elasticity,  are  not  often  seriously  affected  by  a 
contusion  unless  it  be  of  the  severest  grade.-  In  atheromatous 
arteries  a  slight  contusion  may  be  followed  by  rupture  of  the  inner 
coats  and  thrombosis,  the  detachment  of  an  atheromatous  plate, 
sloughing  and  hemorrhage,  or  aneurysm;  if  the  artery  be  the  main 
vessel  of  an  extremity  gangrene  may  ensue.  The  treatment  of 
a  contused  artery  consists  in  absolute  rest,  and  preparations  for  the 
immediate  control  of  hemorrhage  should  it  occur.  In  the  event  of 
thrombosis  prophylactic  measures  against  gangrene  should  be  taken. 
The  treatment  of  thrombotic  gangrene  is  given  in  chap.  ix. 

Traumatic  arterial  stupor  (Viannary)  is  a  locahzed  contraction 
of  an  artery  due  to  trauma,  resulting  in  temporary  impairment  or 
suppression  of  the  circulation.     No  surgical  treatment  is  required. 


VASCULAR    SYSTEM  2Q,^ 

The    condition    has    been    observed    during   exi)h)ralory   operations 
after  severe  injuries. 

Wounds  of  arteries   may   be   incised,   punctured,   gunshot,   or 
huerated.     RujUures    of    arteries    also    come    under    this    heading. 
An  incised  wound  is  followed  by  profuse  hemorrhage,  which  is  more 
severe    in    transverse    than    in    longitudinal    and    oblique    wounds. 
Punctured  wounds  produced  by  very  fine  instruments,  such  as  an 
intestinal  needle,  cause  but  little  hemorrhage,  which  is  easily  and 
permanently  controlled  by  pressure  applied  for  a  short  time.     If  the 
opening  is  of  larger  size  the  bleeding  is  copious  and  may  exsanguinate 
the  patient,  or  if  the  wound  in  the  skin  is  closed  by  suture,  clot, 
or  dressing,  a  diffuse  traumatic  aneurysm  may  develop.     Gunshot 
injuries  are  usually  contusions  or  lacerations,  although  the  modern 
bullet  may  produce  a  clean-cut  wound  and  an  alarming  or  fatal 
hemorrhage.     A  lacerated  wound  involving  the  entire  circumference 
of  an  artery  is  usually  followed  by  slight  hemorrhage,  owing  to  the 
curling  up  of  the  internal  coat,  the  contraction  of  the  middle  coat, 
and  the  prolapse  of  the  stretched  external  coat  over  the  end  of  the 
artery.     Secondary  hemorrhage,  however,  is  Hkely  to  occur  unless 
the  vessel  is  permanently  secured  by  a  ligature.     Partial  lacerations 
do  not  permit  retraction  and  contraction,  hence  spontaneous  hemos- 
tasis  is  uncommon.     Rupture  may  follow  severe  injuries  or  strains, 
particularly  in  the  presence  of  atheroma,  and  the  surgeon  should 
always  have  this  injury  in  mind  when  reducing  an  old  dislocation, 
when  forcibly  straightening  a  contracted  joint,  or  when  giving  ether 
to  an  aged  individual.     Partial  rupture,  i.e.,  of  the  middle  and  inner 
coats,  may  be  regarded  as  a  contusion.     Complete  rupture  results  in  a 
lacerated  wound.     Unless  the  blood  escapes  through  an  external 
wound  or  into  one  of  the  large  cavities  of  the  body,  a  difuse  trau- 
matic aneurysm  (false  traumatic  aneurysm,  arterial  hematoma)  devel- 
ops, the  symptoms  of  which  differ  somewhat  from  those  of  a  true 
aneurysm,  owing  to  the  fact  that  the  effused  blood  forms  a  soft  clot 
which  is  constantly  enlarged  by  the  leaking  artery.     There  is  sudden 
and    acute   pain,    followed    by   rapid   sweUing   and,   after   a   time, 
by  ecchymosis  of  the  skin.     The  size  of  the  swelling  is  enormous 
when,  as  in  the  axilla,  the  tissues  are  lax,  and  small  when  growth  is 
restrained  by  dense  fascia,  e.g.,  in  the  palm  and  at  the  bend  of  the 
elbow.     It  is  tense,  seldom  fluctuates,  cannot  be  reduced  by  pres- 
sure, and  owing  to  the  absence  of  a  distinct  wall  is  more  irregular  and 
not  as  sharply  defined  as  a  true  aneurysm.     Pulsation  is  usually 
present,  thrill  and  bruit  often  absent,  but  these  signs  depend  upon  the 
size  of  the  opening  in  the  artery.     Even  when  the  wound  does  not 


294  MANUAL    OF    SURGERY 

involve  the  entire  circumference  of  the  artery,  the  pulse  below  may 
be  absent  as  the  result  of  pressure  from  the  effused  blood,  and  this 
leads  to  coldness,  numbness,  pallor,  and  partial  paralysis  of  the 
limb.  The  constitutional  symptoms,  which  are  those  of  hemorrhage, 
vary  with  the  amount  of  blood  extravasated.  The  swelling  may 
rupture,  resulting  in  immediate  death;  suppurate  with  the  same 
result;  persist  as  an  aneurysm;  cause  gangrene  by  pressure  on  the 
vessels  of  the  limb;  or  the  blood  may  coagulate,  the  opening  in  the 
vessel  heal,  and  the  clot  be  absorbed  or  organized. 

Dry  wounds  of  arteries  (Fiolle)  attracted  notice  during  the  war. 
Clinically  there  is  no  bleeding,  external  or  internal,  and  no  hema- 
toma, but  later  secondary  hemorrhage  or  an  aneurysm  may  develop. 
Arterial  wounds  without  bleeding  are  due  to  laceration  (vide  supra) ; 
associated  contusion,  extending  some  distance  along  the  vessel  and 
producing  thrombosis;  obturation  of  the  opening  in  the  artery  by  the 
projectile,  a  piece  of  clothing,  a  fragment  of  leather,  or  other  foreign 
body;  or  to  a  concomitant  wound  of  a  vein  and  an  artery,  the  blood 
passing  from  the  artery  into  the  vein  (arteriovenous  aneurysm), 
not  only  because  this  route  presents  the  least  resistance,  but  also 
because  of  the  venous  aspiration. 

The  treatment  of  wounds  of  arteries  is  that  of  hemorrhage; 
ruptures  are  dealt  with  in  the  same  way  as  open  wounds,  after  making 
an  incision  to  expose  the  source  of  bleeding. 

Arterial  varix  corresponds  to  a  varicose  vein,  a  single  artery  is 
dilated,  elongated,  thickened,  and  tortuous.  When  a  number  of 
adjacent  arteries  are  similarly  affected,  the  condition  is  called  cirsoid 
aneurysm.  Cirsoid  aneurysm  {plexiform  angioma,  racemose  aneurysm, 
aneurysm  by  anastomosis)  is  most  frequently  found  in  the  scalp,  and  less 
commonly  in  the  extremities,  labia  pudendi,  and  spermatic  cord. 
Some  cases  develop  from  a  preexisting  angioma,  some  after  trauma, 
and  some  spontaneously.  It  can  be  mistaken  for  no  other  condition, 
as  the  pulsating  varicose  arteries  are  readily  seen  and  felt.  Thrill  and 
bruit  are  often  present,  and  pressure  on  the  main  feeding  artery 
materially  reduces  the  size  of  the  mass  and  the  force  of  the  pulsation. 
The  skin  is  usually  thinned  and  sometimes  ulcerates,  giving  rise  to 
alarming  hemorrhage.  Excision  is  the  best  treatment,  but  is  often 
impracticable.  Among  other  methods  which  have  been  tried  are 
ligation  or  compression  of  the  main  artery  or  arteries  of  supply, 
galvano-cauterization,  electrolysis,  the  X-rays,  and  the  injection  of 
coagulating  fluids.  When  affecting  the  hand  amputation  may  be 
required. 

Aneurysm  is  a  hollow  tumor  containing  blood  and  communicating 


VASCULAR    SYSTEM 


295 


with  the  lumen  of  an  artery.  Excluding  the  cirsoid  variety,  which 
has  just  been  described  and  which  is  really  a  form  of  arterial  varix, 
aneurysms  are  divided  primarily  into  the  simple,  or  arterial,  and  the 
arteriovenous.  When  referring  to  the  former,  however,  it  is  cus- 
tomary to  employ  the  term  aneurysm  without  a  qualifying  adjective. 
The  parts  of  an  aneurysm  are,  (i)  the  sac  wall,  (2)  the  contents, 
and  (3)  the  mouth,  i.  The  sac  wall  is  composed  of  one  or  more  of 
the  arterial  coats  {true  aneurysm)  or  of  condensed  perivascular 
tissues  {false  aneurysm).  As  a  matter  of  fact,  the  walls  of  any 
aneurysm  of  large  size  consist,  not  of  the  walls  of  the  vessel,  but  of 
fibrous  tissue,  and  even  a  false  aneurysm  which  has  existed  for  any 
length  of  time  may  be  lined  by  a  structure  identical  with  the  intima. 


Fig.    113. — Thoracic  aneurysm  showing  laminated  clot. 


2.  The  contents  vary  according  to  the  size,  character,  and  duration 
of  the  aneurysm.  At  first  the  contents  are  only  fluid  blood.  As  the 
aneurysm  enlarges,  however,  and  becomes  more  and  more  saccu- 
lated, particularly  if  the  mouth  remains  small  or  is  so  located  as  to 
protect  the  walls  from  the  full  force  of  the  circulation,  the  blood  is 
thrown  into  eddies,  and  this  leads  to  the  separation  of  fibrin,  which 
is  deposited  on  the  interior  of  the  sac  in  concentric  layers  (Fig.  113), 
the  outer  and  older  layers  being  dry  and  light  in  color,  the  inner  and 
younger  soft  and  red.     Spontaneous  cure  may  be  effected  in  this  way. 

3.  The  month  of  the  sac  is  the  portal  through  which  the  blood  enters 
the  aneurysm;  upon  its  size  and  situation  depends  to  a  large  extent 
the  rapidity  with  which  the  aneurysm  enlarges. 

According  to  whether  the  whole  or  only  portion  of  the  circum- 


296  MANUAL    OF    SURGERY 

ference  of  an  artery  is  involved  an  aneurysm  is  said  to  be  fusiform 
(tubulated)  or  sacculated. 

Fusiform,  or  tubulated  aneurysm,  is  a  dilatation  and  elongation  of  a 
section  of  an  artery.  It  is  most  frequent  in  the  cranium,  the  thorax, 
and  the  abdomen,  and  is  always  spontaneous  in  origin.  Although 
the  walls  are  seldom  coated  with  layers  of  fibrin,  rupture  is  unusual, 
death  generally  being  due  to  pressure  upon  the  surrounding  organs. 
Sacculated  aneurysm  springs  from  the  side  of  an  artery,  rarely 
from  the  side  of  a  fusiform  aneurysm.  There  are  two  forms,  the 
circumscribed,  in  which  the  sac  wall  is  distinct  and  complete,  and  the 
diffuse,  in  which  the  blood  has  extravasated  into  the  surrounding 
tissues.  The  latter  is  said  to  be  primitive  when  due  to  rupture  of  an 
artery  (vide  supra),  consecutive  when  due  to  rupture  of  an  aneurysm 
{vide  infra) . 

According  to  etiology  aneurysms  are  divided  into  the  traumatic 
and  the  spontaneous. 

Traumatic  aneurysm  may  be  true  or  false,  but  is  always  saccu- 
lated. True  traumatic  aneurysm  may  result  from  an  arterial  contu- 
sion which  causes  the  inner  coats  to  rupture,  or  from  a  wound  of  the 
outer  coats,  leading  to  a  hernia  of  the  intima  {hernial  aneurysm) . 
False  traumatic  aneurysm  follows  a  penetrating  wound  or  a  complete 
rupture  of  an  artery  (see  "Wounds  of  Arteries")- 

Spontaneous,  or  idiopathic  aneurysms,  may  be  congenital  or 
acquired. 

Congenital  aneurysms  are  rare,  and  due  to  defective  development 
of  the  elastic  elements  of  the  arteries,  hence  often  multiple. 

Acquired  spontaneous  aneurysms,  although  occasionally  due  to 
infective  softening  of  the  vessel  walls  from  the  impaction  of  an 
embolus  {embolic  aneurysm) ,  to  ulceration  of  the  outer  coats  {aneu- 
rysm by  erosion),  or  of  all  the  coats  (e.g.,  when  an  artery  perforates 
into  an  abscess),  are  almost  always  the  result  of  chronic  arteritis 
combined  with  an  increase  in  the  blood  pressure.  As  has  already 
been  pointed  out,  chronic  arteritis,  particularly  the  syphilitic  va- 
riety, causes  marked  degenerative  changes  in  the  musculo-elastic 
tunica  media,  and  this,  especially  in  the  early  stages,  before  compen- 
satory thickening  of  the  intima  occurs,  leads  to  aneurysmal  dilata- 
tion. In  dissecting  aneurysm,  which  is  a  rare  form  confined  almost 
exclusively  to  the  aorta,  the  blood  makes  its  way  through  an  athero- 
matous ulcer  and  dissects  the  outer  from  the  inner  half  of  the  middle 
coat,  forming  a  sort  of  sac,  which  may  again  open  into  the  artery 
through  another  atheromatous  ulcer,  or  rupture  into  the  perivascular 
tissues.     Increase  in  the  blood  pressure,  the  result  of  hypertrophy  of 


VASCULAR    SYSTEM 


297 


the  heart,  strains,  hi})orious  oecu])ati()ns,  and  violent  exercise,  is  an 
important  factor  when  combined  with  disease  of  the  arteries,  hence 
the  predisposition  of  the  male  sex  (7  to  i),  and  of  the  fourth  and  fifth 
decades,  during  which  arteriosclerosis  frequently  begins,  but  during 
which  the  bodily  condition  is  such  as  to  lead  to  overexertion. 

The  symptoms  of  aneurysm  are,  (i)  those  peculiar  to  the  aneu- 
rysm itself  and  (2)  those  due  to  pressure,  i.  The  syniploms  peculiar 
to  the  aneurysm  itself  are,  the  presence  of  a  sweUing  in  the  line  of  an 
artery;  movability  of  the  tumor,  in  the  absence  of  adhesions,  trans- 
versely to  but  not  in  the  axis  of  the  artery;  reducibility  on  direct 
pressure  and  fluctuation,  but  only  in  the  early  stages  when  the  walls 
are  thin  and  the  contents  are  fluid;  pulsation  synchronous  with  each 
cardiac  systole  and  expansile 
in  character,  i.e..  in  all  direc- 
tions, so  that  the  palpating 
fingers  are  not  only  lifted  but 
separated;  cessation  of  pulsa- 
tion, with  shrinkage  and  soften- 
ing of  the  tumor,  when  proxi- 
mal pressure  is  made  on  the 
artery,  distal  pressure  acting 
in  a  reverse  manner;  the  pre- 
sence over  the  sac  and  along 
the  artery  of  a  systolic  bruit, 
which  is  usually  loud  and 
harsh;  occasionally  a  thrill 
corresponding  with  the  bruit; 
and  retardation  of  the  pulse 
below,  due,  not  to  pressure, 
but  to  the  additional  time  con- 
sumed by  the  blood  current  in  passing  through  the  aneurysm,  hence 
almost  a  pathognomonic  sign.  2.  The  pressure  symptoms  are  similar 
to  those  of  other  tumors.  Pressure  on  the  artery  causes  diminution 
in  the  size  of  the  pulse  distal  to  the  tumor,  hence  enlargement  of  the 
collateral  arteries;  on  the  veins  edema  and  distention  of  their  super- 
ficial branches;  on  the  nerves  pain  and  possibly  paralysis  and  trophic 
disorders;  on  the  muscles  displacement  and  atrophy;  on  the  bones 
erosion,  severe,  constant,  boring  pains,  and  occasionally  spontaneous 
fracture;  on  the  trachea  dyspnea;  on  the  esophagus  dysphagia;  on  the 
recurrent  laryngeal  nerve  change  in  the  voice  and  brassy  cough;  on 
the  cervical  sympathetic  nerve  dilatation  of  the  pupil  and  widening 
of  the  palpebral  fissure,  and  later  contraction  of  the  pupil  and  ptosis 


Pig.  114. — Aneurysm  oi  the  innominate 
artery  treated  by  wiring  and  electrolysis. 
Note  ptosis  from  pressure  on  the  cervical 
sympathetic  nerve. 


298  MANUAL    OF    SURGERY 

(Fig.  114);  on  the  thoracic  duct  inanition;  on  the  phrenic  nerve 
hiccough. 

The  duration  of  aneurysm  is  usually  a  matter  of  some  years, 
spontaneous  recovery  or  death  being  the  natural  termination. 
Spontaneous  recovery  is  rare.  It  may  be  due  to  obliteration  of  the  sac 
with  laminated  fibrin;  to  suppression  of  the  circulation  within  the 
sac,  the  result  of  the  impaction  of  an  embolus  above  or  below  the 
mouth,  or  the  pressure  of  the  aneurysm  itself  on  the  artery;  or  to 
inflammation  of  the  sac.  The  aneurysm  becomes  solid,  and  is 
ultimately  represented  by  a  mass  of  fibrous  tissue.  Death  is  the 
result  of  rupture  of  the  sac,  pressure  upon  important  structures, 
cerebral  embolism,  or  sepsis  from  suppuration  of  the  sac  or  gangrene 
of  the  parts  nourished  by  the  artery. 

Rupture  of  an  aneurysm  is  the  result  of  stretching  and  thinning  of 
the  wall  from  intrasaccular  tension,  or  of  ulceration,  suppuration,  or 
gangrene  of  the  sac.  Rupture  through  the  skin  may  be  immediately 
fatal,  or  death  may  be  deferred  several  days,  the  blood  leaking  from  a 
small  opening  {leaking  aneurysm) ,  which  is  at  times  temporarily  plugged 
by  a  clot.  Rupture  internally,  into  one  of  the  cavities  or  hollow 
organs,  causes  sudden  pain,  symptoms  of  acute  anemia,  and  death. 
If  the  aneurysm  breaks  into  the  esophagus  or  trachea  blood  will  pour 
from  the  mouth.  Rupture  into  the  subcutaneous  tissues  is  an- 
nounced by  severe  pain,  increase  in  the  size  of  the  swelling,  indis- 
tinctness of  its  outline,  diminution  or  disappearance  of  pulsation  and 
bruit  owing  to  coagulation  of  the  blood,  and  cessation  of  the  pulse 
below  the  swelling.  Death  from  acute  anemia  follows,  or  if  the 
surrounding  tissues  restrain  the  blood,  a  consecutive  false  aneurysm 
develops. 

Inflammation  of  the  sac,  when  mild  in  character,  thickens  the  walls 
and  encourages  coagulation  of  the  blood.  In  the  severer  form  there 
is  redness  of  the  skin,  pain,  elevation  of  the  local  temperature,  and 
edema,,  the  last  causing  the  aneurysm  to  become  less  distinct  in 
outline.     Suppuration  or  gangrene  of  the  sac  may  follow. 

Gangrene  of  the  parts  distal  to  the  aneurysm  may  be  caused  by 
obliteration  of  the  artery  from  the  pressure  of  the  aneurysm,  from 
the  pressure  of  extravasated  blood  when  rupture  occurs,  from  the 
impaction  of  an  embolus  derived  from  the  aneurysm,  or  from  throm- 
bosis the  result  of  inflammation. 

The  diagnosis  of  aneurysm  may  be  difficult  or  even  impossible, 
since  pulsation  and  bruit  may  be  absent  in  an  aneurysm,  and  present 
in  other  tumors.  Any  swelling,  whether  pulsating  or  not,  in  the 
line  of  an  artery  must  be  carefully  investigated  for  evidences    of 


VASCULAR   SYSTEM  299 

aneurysm.  Perhaps  the  most  frequent  mistake  is  to  take  a  non- 
pulsating  inflamed  aneurysm  at  the  base  of  the  neck  for  an  abscess. 
A  cyst,  tumor,  or  abscess  lying  upon  an  artery  may  be  lifted  with 
each  pulse  beat,  and  cause  a  murmur  by  narrowing  the  artery,  but 
the  pulsation  is  not  expansile,  and  it,  with  the  murmur,  ceases  if  the 
tumor  can  be  lifted,  or  by  posture  made  to  fall  away  from  the  vessel 
(Figs.  115,  116).  Compression  of  the  artery  above  or  below  the 
tumor  does  not,  as  in  aneurysm,  affect  the  size  and  the  consist- 
ency of  the  swelling,  and  after  removing  the  proximal  compression 
the  first  pulsation  is  of  full  strength,  while  in  aneurysm  it  may  take 
several  pulse  waves  to  distend  the  sac  and  make  the  pulsation  as 
strong  as  it  was  before.  Any  tumor  which  presses  on  an  artery 
may  make  the  distal  pulse  smaller,  but  retardation  is  caused  only 
by  aneurysm,  a  sign  which  becomes  more  evident  after  temporarily 
compressing  the  artery  above  the  swelling;  in  a  non-aneurysmal 
tumor  the  pulse  reappears  at  once,  in  an  aneurysm  several  beats 


t5 


Pig.  115. — Transmitted  pul-  Pig.  116. — Expansile  pul- 

sation.     Tumor    over    artery  sation.       Aneurysm    spring- 

(A).     Arrow    indicates    direc-  ing  from    artery    (A),    from 

tion  of  the  pulsation.  which  it  cannot  be  separated. 

Arrows  indicate  direction  of 

the  pulsation. 

may  be  lost.  The  exploratory  needle  may  sometimes  be  employed 
to  determine  the  contents  of  the  swelhng.  The  X-ray  shows  a 
distinct  shadow  in  aneurysm,  the  pulsation  of  which  can  be  observed 
with  the  fluoroscope.  Radiography  is  of  particular  value  for  the 
diagnosis  of  aneurysms  in  the  cranium,  the  chest,  and  the  abdomen. 
Angiomata  and  round-celled  sarcomata  may  have  expansile  pulsa- 
tion and  bruit,  but  may  not  correspond  to  the  line  of  an  artery  or 
affect  the  pulse  below.  Pressure  on  the  artery  proximal  to  the  growth 
may  cause  it  to  shrink,  but  not  so  markedly  as  in  aneurysm,  and  it 
may  be  more  irregular,  less  distinct  in  outline,  and  more  variable 
in  consistency;  a  ruptured  or  an  inflamed  aneurysm  also  may  be 
indistinct  in  outhne.  In  sarcoma  the  superficial  veins  are  dilated 
over  and  proximal  to  the  growth,  in  an  aneurysm  causing  pressure 
on  the  deep  veins  the  superficial  collaterals  are  most  numerous  distal 
to  the  swelling,  and  the  limb  is  edematous.  The  X-ray  usually 
fails  to  demonstrate  round-celled  sarcoma,  unless  it  has  invaded  osse- 
ous tissue.     A  cervical  rib  or  a  neoplasm  under  an  artery  may  simu- 


300  MANUAL    OF    SURGERY 

late  an  aneurysm,  but  only  the  artery,  and  not  the  growth  which 
displaces  it,  pulsates.  A  cervical  rib  and  certain  forms  of  neoplasm 
may  be  shown  by  the  X-ray.  Aneurysmal  pain  has  been  mistaken 
for  rheumatism,  neuralgia,  lumbago,  etc. 

The  treatment  of  aneurysm  may  be  medical  or  surgical. 

Medical  treatment  aims  to  decrease  the  blood  pressure  and  in- 
crease the  coagulabihty  of  the  blood.  It  is  used  as  an  auxiliary  to 
surgical  treatment,  or  when  surgical  treatment  cannot  be  apphed. 
TiifnelVs  method  consists  in  absolute  rest  in  bed  for  at  least  three 
months,  and  a  daily  diet  of  six  ounces  of  bread,  a  little  butter,  three 
ounces  of  meat,  and  eight  ounces  of  milk.  Among  the  drugs  recom- 
mended are  iodid  of  potassium,  especially  in  syphilitic  cases,  iron, 
acetate  of  lead,  ergotin,  aconite,  veratrum  viride,  and  calcium  chlorid. 
Opium  or  the  bromids  are  used  for  pain,  purgatives  to  thicken  the 
blood  and  prevent  straining  from  constipation.  Venesection  has 
been  employed  when  the  blood  pressure  is  very  high.  Eggs  have 
been  recommended  to  increase  the  coagulability  of  the  blood.  Lan- 
cereaux  reports  good  results  from  the  hypodermatic  injection  of  a 
I  or  2  per  cent,  solution  of  gelatin  in  normal  salt  solution;  about  200 
cc.  are  injected  beneath  the  skin  of  the  thigh  every  ten  days,  until 
from  ten  to  thirty  injections  have  been  given.  As  twenty-three 
deaths  from  tenanus  have  followed  this  method  of  treatment 
(Dieulafoy),  the  gelatin  should  be  thoroughly  sterilized,  or,  better, 
since  its  coagulative  effects  are  not  destroyed  by  digestion,  adminis- 
tered by  mouth.  Gelatin  is  said  to  be  irritating  to  the  kidneys, 
hence  is  contraindicated  in  the  presence  of  renal  disease.  Many 
surgeons  doubt  the  efficacy  of  this  treatment. 

The  surgical  treatment  consists  of  (i)  compression  of  the  artery 
or  the  aneurysm;  (2)  the  temporary  or  permanent  introduction  of 
foreign  bodies;  or  (3)  operative  treatment. 

I.  Compression  of  the  sac  itself  by  bandages,  or  by  flexion  of  the 
limb,  e.g.,  in  aneurysms  at  the  bend  of  the  elbow  or  knee,  and  mas- 
sage of  the  sac,  with  the  idea  of  occluding  the  artery  with  a  fragment 
of  the  clot,  are  ancient  methods  which  are  apt  to  be  followed  by 
rupture  or  suppuration  of  the  sac,  or  gangrene  of  the  hmb.  Reid's 
method  of  rapid  cure  by  compression  aims  to  retain  the  blood  in  the 
sac  until  it  coagulates.  The  patient  is  anesthetized,  and  an  elastic 
bandage  applied  from  the  extremity  to  the  root  of  the  hmb,  exclud- 
ing the  aneurysm,  which  should  be  full  of  blood.  A  tourniquet  is 
then  apphed  above  the  band,  and  allowed  to  remain  for  an  hour 
and  a  half,  after  which  it  is  gradually  loosened,  so  as  to  prevent  a 
sudden  gush  of  blood,  which  might  wash  away  the  clot.     This  method 


VASCULAR   SYSTEM  301 

is  occasionally  successful,  hut  is  often  followed  by  gangrene. 
Pressure  on  the  artery  feeding  the  aneurysm  may  be  made  by  the  thumb 
(digital  pressure),  a  method  which  requires  relays  of  assistants, or 
by  means  of  tourniquets  or  compressors  (instrumental  compression) , 
the  pressure  being  continuous  or  intermittent.  The  skin  should  be 
protected  with  a  piece  of  chamois  and  by  shifting  the  point  of  pres- 
sure, and  the  main  vein  and  nerves  avoided.  Although  some  assert 
that  it  is  not  essential  to  obliterate  the  pulse,  complete  suppression 
of  the  circulation  through  the  sac,  gives  the  best  results.  In  the 
intermittent  method  pressure  is  made  for  a  number  of  hours  each  day, 
but  the  patient  allowed  to  sleep  at  night.  In  the  continuous  method 
pressure  is  sometimes  maintained  for  two  or  three  days,  but  if 
coagulation,  which  reveals  itself  by  absence  of  pulsation  and  hardening 
of  the  aneurysm,  does  not  occur  within  thirty-six  hours  the 
method  should  be  abandoned.  As  the  pressure  is  agonizing  to  the 
patient  narcotics  are  required.  Pressure  upon  the  artery  distal  to 
the  aneurysm  may  be  employed  as  an  aid  to  proximal  pressure,  or 
in  cases,  such  as  aneurysm  of  the  root  of  the  carotid,  in  which  proxi- 
mal pressure  cannot  be  applied.  Intermittent  pressure  is  useful  in 
dilating  the  collaterals  before  the  apphcation  of  a  ligature,  thus 
preventing  gangrene.  The  treatment  of  aneurysm  by  proximal 
pressure  is  successful  in  about  50  per  cent,  of  the  cases  and  is  attended 
by  little  danger,  but  is  tedious,  extremely  painful,  and  is  rapidly 
being  displaced  by  the  operative  methods. 

2.  The  introduction  of  foreign  bodies  into  the  sac  should  be  per- 
formed only  in  inoperable  cases.  Acupuncture  consists  in  the  intro- 
duction of  fine  needles  in  such  a  way  that  they  will  cross  one  another 
and  whip  the  fibrin  from  the  blood;  they  are  withdrawn  after  several 
days.  Macewen's  method  consists  in  the  introduction  of  a  long 
needle,  with  which  the  whole  lining  membrane  of  the  sac  is  scratched, 
the  idea  being  to  excite  a  mild  inflammation  which  will  cause  the 
walls  to  thicken  and  the  blood  to  coagulate.  Moore^s  method  consists 
in  the  introduction  of  a  number  of  yards  of  coiled  steel  wire  through 
a  cannula;  the  wire  assumes  a  spiral  shape  in  the  sac,  and  is  allowed 
to  remain  permanently.  Silk,  horse-hair,  catgut,  and  other  materials 
have  been  used  in  a  similar  way.  Electrolysis  may  be  employed  by 
introducing  two  needles  which  are  insulated  where  they  come  in 
contact  with  the  tissues.  The  points  of  the  needles  are  slightly 
separated,  and  a  constant  current  of  from  5  to  6  milliamperes  passed 
through  the  sac  for  from  one-half  to  two  hours.  A  combination  of 
the  last  two  methods  (Moore-Corradi  method)  has  proven  of  some 
value  in  sacculated  aneurysms  of  the  aorta.     The  author  has  ob- 


302  MANUAL    OF    SURGERY 

tained  marked  and  lasting  improvement  in  one  case,-  and  one  case 
has  been  reported  in  which  cure  apparently  occurred.  From  five 
to  fifteen  feet  of  drawn  gold  wire,  according  to  the  size  of  the  sac,  is 
introduced  through  a  gold  cannula  insulated  with  porcelain,  and 
connected  with  the  positive  pole  of  a  galvanic  battery,  the  negative 
pole  being  apphed  to  the  abdomen  or  back.  The  current  is  gradu- 
ally increased,  often  to  80  milliamperes,  and  as  gradually  decreased 
to  zero,  from  forty-five  minutes  to  one  and  one-half  hours  being 
consumed  in  the  process;  the  cannula  is  then  withdrawn,  and  the 
wire  cut  off  close  to  the  skin,  beneath  which  it  is  buried.  The 
method  is  not  without  danger.  Coagulating  injections,  such  as 
Monsel's  solution,  acetate  of  lead,  and  tannin,  have  been  employed 
while  pressure  is  made  upon  the  artery  on  both  sides  of  the  aneurysm. 
The  method  is  not  recommended  in  aneurysms  of  the  extremities, 
which  are  better  treated  by  operative  measures,  and  in  other  cases 
it  may  be  followed  by  very  serious  results  owing  to  the  dislodgment 

of  emboli. 
ffl  3.  Operative  treatment  includes  liga- 

Ji         'Hu\Ttn    ^ion,  incision,  endoaneurysmorrhaphy,  ex- 

.---'/^^Hi    '^'^^'^     tirpation,    arterial    anastomosis,    venous 

'^^"^l^.-.-BRAsoop    transplantation  and  amputation. 
jm!^....mf}DRop         Ligation  may  be  performed  in  one  of 
■~^  ^  five  ways  (Fig.  i^i  7) .     AneVs  method  is  liga- 

FiG.  117.— Methods  of  ligation    ^^^^  immediately  above  the  sac.     Hunter's 

for  aneurysm.  -^ 

operation  is  ligation  above  but  some  dis- 
tance away  from  the  sac,  so  that  anastomotic  branches  exist  between 
the  ligature  and  the  aneurysm;  thus  the  blood  supply  to  the  sac  is 
not  completely  cut  off,  but  is  greatly  diminished,  allowing  contrac- 
tion and  gradual  consolidation.  Although  most  surgeons  prefer  the 
Hunter  to  the  Anel  operation,  we  believe  the  former  increases  the 
danger  of  recurrence  if  the  anastomotic  branches  between  the  liga- 
ture and  the  aneurysm  remain  pervious,  and  the  danger  of  gangrene 
of  the  limb  if  these  branches  suffer  obliteration.  The  objection 
that  the  artery  is  more  diseased  near  the  aneurysm  is  not  a  valid 
one,  as  the  degenerative  changes  are  often  more  marked  in  the  seg- 
ment which  would  be  ligated  in  the  high  operation.  Proximal  liga- 
tion is  contraindicated  when  serious  disease  of  the  heart  or  a  coexist- 
ing internal  aneurysm  is  present,  because  of  the  sudden  rise  of  blood 
pressure  that  follows  ligation  of  a  large  artery;  when  compression  of 
the  feeding  artery  does  not  materially  diminish  the  pulsation;  when 
the  arteries  are  extensively  diseased;  when  inflammation  is  present; 
when  gangrene  of  the  limb  is  threatened;  and  when  the  bone  is 


VASCULAR    SYSTEM  303 

deeply  eroded.  The  accidents  which  may  follow  are  secondary 
hemorrhage,  suppuration  and  rupture  of  the  sac,  gangrene  of  the 
limb,  and  secondary  aneurysm  at  the  point  of  ligation.  Return  of 
pulsation  in  the  sac  is  observed  in  the  majority  of  cases  after  a  day 
or  two,  owing  to  the  establishment  of  a  collateral  circulation;  in 
favorable  cases  as  the  sac  contracts  this  diminishes  and  finally  dis- 
appears. Pulsation  beginning  a  number  of  days  after  operation 
generally  means  recurrence  of  the  aneurysm.  Pesquhi's  method,  or 
ligation  above  and  below  the  sac,  is  indicated  only  in  cases  which 
are  better  treated  by  extirpation.  Brasdor's  operation,  or  ligation 
of  the  artery  distal  to  the  sac,  is  employed  only  in  cases  in  which  a 
proximal  ligature  cannot  be  applied,  e.g.,  aneurysm  of  the  root  of 
the  carotid.  Wardrop's  operation  is  ligation  of  one  of  the  branches 
of  the  artery  distal  to  the  ^ 

sac,  e.g.,  ligation  of  the  sub-  • 

clavian  in  aneurysm  of  the ~y^\v    \  \.r\^^-~SHIN 

innominate.  ^^$i^O<^  V'    xX^^^^^^ 

Incision    of   the    sac  ^^^^V^&^^^^P*^ 

(method  of  Antyllus) ,  after  ^^^^^^^^^^  — 

ligating  the  artery  immedi-  ^^'ilml 2 

ately  above  and  below,  is  in-  j,Mfl| i 

dicated  in  the  presence  of  wiWi 

suppuration.      The    sac    is  ^^^^ 

cleared     of     its     contents,  F'G.    h 8.— Diagram  of  obliterated  sacculated 

,                  .   ,                                  ,  aneurysm,  parent  artery   preserved.     (Matas.^   i. 

packed    with     gauze,     and  Sutures  closing  mouth  of  sac.     2.  Lembert  sutures 

allowed  to  granulate.  reducing    size    of    sac.      3.   Through-and-through 

"  sutures  bringing  roof  and  floor  of  sac  m  contact, 

Endoaneurysmorrhaphy  and  tied  over  roll  of  gauze.     4.   Sutures  holding 

f  -ir    ,           t         J  •       \       -ii           1  skin  and  sac  in  contact  with  bottom  of  cavity. 

{Alatas  operation)  will  prob- 
ably be  the  operation  of  the  future  in  all  cases  in  which  the  circulation 
through  the  sac  can  be  provisionally  controlled.  The  circulation  is 
arrested  by  means  of  a  tourniquet  or,  when  this  is  impracticable,  by 
exposure  and  compression  of  the  main  artery  on  each  side  of  the 
aneurysm.  The  sac  is  then  opened  and  emptied,  and,  according  to 
the  character  of  the  aneurysm,  an  obliterative,  restorative,  or  recon- 
structive operation  performed.  In  the  obliterative  operation,  which  is 
indicated  in  a  fusiform  aneurysm,  the  orifices  of  the  sac,  and  of  any 
collateral  arteries  which  may  open  into  the  aneurysm,  are  sutured  with 
chromicized  catgut,  but  the  continuity  of  the  artery  is  not  restored. 
In  the  restorative  operation,  which  is  applicable  only  to  a  small  mouthed 
saccular  aneurysm,  the  mouth  of  the  sac  is  sutured  without  imping- 
ing on  the  lumen  of  the  vessel,  thus  curing  the  aneurysm  without 
cutting  off  the  circulation  of  the  limb.     In  either  case  the  walls  of 


304 


MANUAL    OF    SURGERY 


the  sac  with  the  overlying  skin  are  inverted  and  so  sutured  as  to 
obhterate  the  sac  (Fig.  ii8).  Matas  suggests  that  in  certain  fusiform 
aneurysms  it  may  be  possible  to  reconstruct  the  arterial  channel  by 
suturing  two  folds  of  the  sac  over  a  rubber  catheter,  in  a  manner 
similar  to  the  formation  of  the  canal  in  the  Witzel  gastrostomy. 
The  catheter  is  removed  before  the  last  sutures  are  tied.  Even  in 
cases  in  which  the  circulation  through  the  main  artery  is  stopped, 
gangrene  is  less  likely  to  follow  than  after  other  methods  of  operation, 
because  the  collateral  circulation  is  practically  undisturbed.  The 
state  of  the  collateral  circulation  may  be  determined  before  any  of  the 
operations  mentioned  above  by  the  Matas  method  (see  "Indications 
for  Amputation,"  chap.  xxxi). 

Extirpation  of  the  sac,  after  ligation  of  the  artery  above  and  below, 

is  followed  by  permanent 
cure,  but  in  a  large  aneurysm 
is  a  formidable  operation 
which  may  seriously  interfere 
with  the  collateral  circulation 
and  be  followed  by  gangrene. 
It  is  the  best  operation  for 
aneurysm  of  a  small  artery, 
e.g.,  the  radial,  and  may  be 
tried  previous  to  amputation 
in  cases  which  have  recurred 
after  other  methods  of  treat- 
ment, or  in  cases  in  which 
the  sac  has  ruptured  or  is 
inflamed  and  suppurating. 

End-to-end  anastomosis  of  the  artery,  after  excising  the  sac,  is 
indicated  in  small  traumatic  aneurysms,  but  in  the  spontaneous  variety 
is  less  apt  to  succeed,  because  of  the  diseased  state  of  the  artery. 
Of  nine  operations  of  this  character  eight  were  successful  (Abalos). 
Venous  transplantation  has  been  performed  in  eleven  cases  in 
which,  after  excision  of  the  sac,  the  interval  between  the  ends  of  the 
artery  was  too  great  to  permit  end-to-end  anastomosis.  Six  of  the 
patients  recovered.  The  internal  saphenous  or  the  external  jugular 
is  the  best  vein  from  which  to  take  the  transplant. 

Amputation  of  the  limb  is  indicated  in  gangrene,  in  marked 
erosion  or  dissolution  of  a  joint,  in  some  cases  of  rupture,  suppuration, 
or  secondary  hemorrhage,  and  in  a  rapidly  growing  aneurysm  which 
has  resisted  other  means  .of  treatment.  Amputation  of  the  arm 
has  been  performed  to  lessen  the  quantity  of  blood  flowing  through  a 
subclavian  aneurvsm. 


Fig.  119. — Arteriovenous  aneurysms.  On 
the  left  aneurysmal  varix,  on  the  right  varicose 
aneurysm.  Note  that  below  the  arteriovenous 
fistula,  in  each  instance,  the  artery  is  contracted, 
the  vein  dilated  and  varicose.  The  arrows  in- 
dicate the  direction  of  the  blood  current. 


VASCULAJt    SYSTEM  305 

Arteriovenous  aneurysm  (^i•,^  119)  is  the  condition  resulting 
from  an  abnormal  communication  between  an  artery  and  a  vein. 
The  traumatic  variety  usually  follows  a  stab  or  gunshot  wound;  the 
spontaneous  variety  is  rare  and  results  from  the  rupture  of  an  arterial 
aneurysm  into  a  vein,  the  aorta  and  vena  cava  being  the  vessels 
most  often  affected.  The  artery  may  communicate  directly  with  the 
vein  {aneurysmal  varix)  or  there  may  be  an  intervening  sac  {varicose 
aneurysm). 

The  important  symptoms  are  pulsation  of  the  vein,  which  becomes 
varicose,  and  a  characteristic  thrill  and  bruit,  the  latter  resembling 
the  buzzing  of  a  fly.  Both  thrill  and  bruit  are  continuous,  but  rein- 
forced at  each  cardiac  systole,  and  transmitted  along  the  vein,  both 
centrally  and  peripherally.  Proximal  pressure  on  the  artery,  com- 
pression of  the  intermediary  sac,  or  closure  of  the  arterial  opening 
by  pressure  on  the  vein,  causes  the  swelling  to  shrink,  and  the  thrill, 
bruit,  and  pulsation  to  cease;  distal  pressure  intensifies  these  signs. 
Edema,  cyanosis,  and  motor,  sensory,  and  trophic  disturbances  are 
of  common  occurrence,  while  in  arteriovenous  aneurysm  of  the  com- 
mon carotid  and  jugular,  headache,  vertigo,  and  other  cerebral 
symptoms  may  appear.  The  condition  may  slowly  advance,  or 
remain  stationary  for  years.  Rupture  is  more  frequent  in  varicose 
aneurysm  than  in  aneurysmal  varix. 

The  diagnosis,  even  in  the  absenceof  venous  pulsation,  is  assured 
if  the  characteristic  thrill  and  bruit  are  present.  The  bruit  of  an  art- 
erial aneurysm  is  intermittent,  and,  although  sometimes  propagated 
along  the  artery,  is  never  transmitted  towards  the  heart.  The  venous 
hum,  occasioned  by  pressure  or  anemia,  which  is  at  times  heard  at  the 
root  of  the  neck,  although  continuous  and  transmitted  towards  the 
heart,  is  intensified,  not  by  cardiac  systole,  but  by  diastole  or  inspira- 
tion. In  cirsoid  aneurysm  pulsation  is  uniform  and  confined  to  the 
arteries,  thrill  and  bruit  weak  or  absent;  proximal  compression  of 
the  main  artery  does  not  wholly  suppress  these  signs,  and  the  con- 
dition is  most  frequent  on  the  scalp  and  hand,  where  arteriovenous 
aneurysm  seldom  occurs.  The  differential  diagnosis  between  aneur- 
ysmal varix  and  varicose  anuerysm  is  seldom  possible  without  ex- 
ploratory incision,  although  a  soft,  oval,  fluctuating,  easily-reducible 
swelling  points  to  the  former,  and  a  firm,  irregular,  immobile  tumor 
which  cannot  be  completely  reduced,  to  the  latter. 

The  treatment  of  aneurysmal  varix  is  the  application  of  an  elastic 
bandage.  If  this  does  not  check  the  progress  of  the  growth,  if  pain 
is  severe  or  rupture  threatened,  operation  is  demanded.  Varicose 
aneurysm  should  never  be  treated  expectantly.     The  ideal  operation 


306  MANUAL    OF    SURGERY 

is  separation  of  the  vessels  with  suture  of  the  openings,  thus  preserv- 
ing the  circulation.  We  have  successfully  performed  this  operation 
in  three  instances  (carotid,  brachial,  femoral).  When  suture  of  the 
vessels  is  inapplicable,  extirpation,  after  tying  both  vessels  above  and 
below,  is  the  best  procedure.  Proximal  ligation  of  the  artery,  liga- 
tion of  the  artery  above  and  below,  or  better,  ligation  of  both  vessels 
above  and  below  may  be  indicated  when,  owing  to  dense  adhesions 
or  unfavorable  situation,  extirpation  seems  too  formidable. 

HEMORRHAGE 

Hemorrhage  is  divided,  (i)  according  to  its  cause,  into  spontane- 
ous and  traumatic;  (2)  according  to  the  vessels  injured,  into  arterial, 
venous,  and  capillary;  (3)  according  to  the  time  following  the  injury, 
into  primary,  intermediary,  and  secondary;  and  (4)  according  to  its 
location,  into  external  and  internal. 

I.- — S pontaneous  hemorrhage,  non-traumatic ,{?<  the  result  (i)  of  ul- 
cerative, degenerative,  or  inflammatory  diseases  of  the  vessel  walls ;  (2) 
of  increase  in  blood  pressure,  e.g.,  hypertrophy  of  the  heart,  straining, 
coughing,  vomiting,  and  convulsions;  (3)  of  alterations  in  the  constitu- 
tion of  the  blood,  e.g.,  certain  forms  of  anemia,  notably  progressive 
pernicious  anemia  and  leukemia,  snake  bite,  phosphorous  posioning, 
malaria,  yellow  fever,  jaundice,  scurvy,  septicemia,  and  purpura 
hemorrhagica;  and  (4)  of  obscure  nervous  influences,  e.g.,  hysteria, 
vicarious  menstruation,  and  certain  other  nervous  conditions.  The 
cause  of  bleeding  in  hemophilia  is  not  known.  Traumatic  hemorrhage 
is  the  result  of  wounds  of  vessels,  or  of  contusions  which  weaken  the 
vessel  wall  and  are  followed  by  rupture. 

2.- — In  arterial  hemorrhage  the  blood  is  bright  red,  and  is  pumped 
from  the  vessel  in  spurts  synchronous  with  the  cardiac  systole.  It 
oxygenation  of  the  blood  is  deficient  from  any  cause,  the  blood  may 
be  dark  in  color,  e.g.,  in  deep  narcosis  and  asphyxia.  Pressure  on 
the  artery  between  the  wound  and  the  heart  stops  the  bleeding, 
unless  the  collateral  circulation  is  well  developed ;  pressure  distal  to 
the  wound  augments  the  bleeding  only  when  the  artery  is  incom- 
pletely severed.  In  venous  hemorrhage  the  blood  is  dark  in  color  and 
flows  in  a  steady  stream.  Bleeding  from  the  central  end  of  a  severed 
vein  soon  ceases,  unless  the  valves  are  incompetent  or  absent,  or 
unless  a  large  branch  opens  into  the  vein  between  the  wound  and  the 
next  valve  above.  Pressure  on  the  vein  below  the  wound  checks  the 
bleeding;  proximal  pressure,  if  the  wound  is  lateral,  increases  the 
bleeding.  The  opposite  is  true,  however,  when,  as  in  certain  varices, 
the  circulation  is  reversed.     The  application  of  a  tourniquet  to  the 


VASCULAR    SYSTEM  307 

limb  above  the  wound  makes  the  bleeding  worse,  unless  the  con- 
striction is  tight  enough  to  compress  the  arteries,  when  the  bleeding 
will  cease,  after  the  perijiheral  segment  of  the  vein  and  its  tributaries 
have  emptied  themselves.  Capillary  hemorrhage  is  characterized 
by  a  general  oozing  of  blood.  The  term  parenchymatous  is  sometimes 
applied  to  a  free  general  oozing  from  all  the  vessels. 

3. — Primary  hemorrhage  occurs  at  the  time  ot  injury.  Inter- 
mediary, reactionary ,  recurrent,  or  consecutive  hemorrhage  is  the 
bleeding  which  recurs  within  twenty-tour  hours  of  the  cessation  of 
primary  hemorrhage.  It  is  due  to  the  cutting  through  (in  friable, 
inflammatory,  or  neoplastic  tissue,  or  in  atheroma),  slipping  off, 
untying,  or  breaking  of  a  ligature;  to  neglect  of  the  distal  end  of  a 
severed  artery,  which  may  start  to  bleed  only  after  the  collateral 
vessels  have  dilated;  to  dislodgment  of  a  clot  as  the  result  of  restless- 
ness (local  or  general) ;  or  to  the  washing  of  coagula  from  the  ends  of 
the  vessels  as  the  result  of  increased  blood  pressure  coincident  with 
reaction  from  shock.  Secondary  hemorrhage  occurs  after  twenty- 
four  hours.  It  may  be  due  to  the  causes  mentioned  above,  but  is 
usually  the  result  of  infection,  which  opens  the  vessels  by  ulceration 
or  sloughing,  by  breaking  down  the  coagulum,  or  by  disintegrating 
an  absorbable  ligature.  Secondary  hemorrhage  of  the  septic  type  is 
often  delayed  for  a  week  or  longer,  and  usually  manifests  itself  by 
repeated  bleedings,  which  are  at  first  slight,  but  grew  progressively 
more  copious.  The  patient  must  never  be  treated  expectantly,  even 
though  the  bleeding  is  slight  or  has  ceased,  becaused  it  is  almost 
certain  to  begin  again. 

4. — In  external  hemorrhage  the  blood  escapes  from  an  external 
wound.  In  internal  hemorrhage  it  accumulates  in  the  tissues  (extrav- 
asation, diffuse  traumatic  aneurysm),  in  one  of  the  cavities  of  the 
body  (hematocele),  or  in  one  of  the  hollow  viscera.  Various  other 
names  are  applied  to  hemorrhage  according  to  its  location,  such  as 
epistaxis  (nose  bleed),  hematemesis  (vomiting  of  blood),  metrorr- 
hagia (uterine  hemorrhage  between  the  menses),  hemothorax 
(bleeding  into  the  pelural  cavity),  etc. 

The  constitutional  symptoms  of  acute  hemorrhage  are  rapid,  feeble, 
easily  obliterated,  dicrotic  pulse;  subnormal  temperature  with  cold, 
clammy  skin;  increased  and  frequently  irregular  respirations  with 
dyspnea  {air  hunger) ;  marked  pallor  of  the  skin  and  mucous  mem- 
ranes;  failing  sight  and  dilatation  of  the  pupils;  ringing  in  the  ears 
{tinnitus  aurium);  restlessness,  and  great  anxiety;  muscular  twitch- 
ing or  convulsions;  thirst,  and  sometimes  nausea,  vomiting,  or  de- 
lirium; recurring  attacks  of  vertigo  or  syncope;  and  finally,  in  fatal 


3o8  MANUAL    OF    SURGERY 

cases,  collapse  and  death.  These  symptoms  vary  in  frequency  and 
intensity  according  to  the  amount  of  blood  lost  and  the  rapidity  with 
which  such  loss  takes  place.  The  most  important  symptoms  are  a 
rising  pulse,  a  falling  temperature,  and  increasing  pallor.  It  should 
be  noted,  however,  that  the  pulse  may  be  slow  in  intracranial  hem- 
orrhage, owing  to  cerebral  compression;  in  intrapericardial  hem- 
orrhage owing  to  pressure  on  the  heart ;  and  in  some  cases  of  rupture 
of  the  liver,  owing  to  bihary  absoprtion;  and  that  the  temperature 
may  be  high  in  pontine  hemorrhage.  Pallor  in  the  negro  is  detected 
by  inspecting  the  conjunctivae  and  the  mucous  membrane  of  the  lips. 
A  sudden  violent  hemorrhage  may  cause  death  in  a  few  seconds, 
small  but  repeated  bleedings  may  not  effect  the  same  result  for  years. 
It  is  said  that  loss  of  half  of  the  blood  (the  total  amount  of  blood  is  an 
eighth  of  the  body  weight)  usually  causes  death.  The  effects  of 
hemorrhage,  however,  are  much  greater  in  infants,  in  the  aged,  and 
in  the  debilitated,  and  much  less  in  the  plethoric,  and  in  women 
during  parturtion  after  a  severe  hemorrhage.  Reaction  is  attended 
by  a  slight  rise  in  temperature  {hemorrhagic  fever) ,  the  result  of  nervous 
influences  or  the  absorption  of  fibrin  ferment.  There  is  sometimes  a 
low  form  of  dehrium,  and  as  the  result  of  the  asthenia,  the  patient  is 
predisposed  to  infective  processes.  Although,  owing  to  the  contrac- 
tion of  the  vessels  and  the  absorption  of  fluids,  the  blood  pressure  is 
quickly  restored,  the  number  of  red  cells,  the  amount  of  hemoglobin, 
and  the  specific  gravity  and  coagulation  time  of  the  blood  are  reduced, 
while  the  number  of  leukocytes  is  increased  for  a  number  of  days,  no 
doubt  the  result  of  the  large  quantity  of  lymph  taken  up  by  the 
circulation  at  this  time. 

The  most  important  symptoms  of  chrtniic  hemorrhage,  i.e.,  fre- 
quently repeated  small  bleedings,  are  pallor,  rapid  dicrotic  pulse, 
dyspnea,  hemic  murmurs  over  the  heart,  edema  of  the  face  and  feet, 
predisposition  to  syncope  on  slight  exertion,  and,  as  pointed  out 
above,  the  blood  changes  of  secondary  anemia. 

Natural  arrest  of  hemorrhage  may  ])e  only  temporary,  or  it  many 
be  permanent.  Temporary  hemostasis  is  effected  in  the  following 
manner:  A  severed  artery  retracts  within  its  sheath  because  of  its 
elasticity;  its  orifice  is  diminished  in  size  by  contraction  of  the  trans- 
verse muscular  libers  in  the  media,  by  a  curling  up  of  the  intima,  and 
by  the  pressure  of  the  perivascular  tissues,  and  as  the  result  of  the  fall 
in  blood  pressure  and  the  increased  cogulability  of  the  blood  conse- 
quent upon  hemorrhage,  a  clot  {external  coagulum)  gradually  forms 
in  and  around  the  sheath,  until  it  is  sufficiently  firm  to  resist  the 
diminishing  force  of  the  circulation.     The  bleeding  is  now  checked, 


VASCl'LAK    SYSTEM  309 

and  coagulation  proceeds  \\itbin  the  vessel  {internal  coagulum)  until, 
in  some  cases,  the  first  collateral  branch  is  reached.  This  clot  may 
be  washed  out  with  the  increase  in  the  force  of  the  heart  during  the 
reaction  from  shock,  hence  over-stimulation  should  be  avoided. 
After  wounds  of  veins  the  process  is  much  the  same,  although  for  the 
reasons  pointed  out  under  thrombosis,  coagulation  occurs  more 
promptly.  Capillary  bleeding  soon  ceases  as,  owing  to  the  minute 
size  of  the  vessels,  the  smallest  coagula  readily  fill  their  orifices. 
Permanent  hemoslasis  is  the  result  of  displacement  of  the  internal  clot 
by  fibrous  tissue,  the  changes  being  those  already  described  under 
"Repair."  For  the  fate  of  extravasated  blood  see  section  on 
"Contusions." 

Delayed  Jiemostasis,  in  addition  to  the  conditions  mentioned  under 
"Spontaneous  Hemorrhage,''  may  be  due  to  a  large  wound  in  the 
tissues  over  the  injured  vessel,  the  tissues  offering  no  obstacle  to  the 
free  escape  of  blood;  an  incised  wound,  or  incomplete  division,  of  a 
vessel,  the  latter  preventing  contraction  and  retraction;  gaping  of  a 
vessel  because  of  rigidity  of  its  walls,  as  in  varix,  or  because  of  its 
attachment  to  environing  structures,  such  as  is  normally  the  case 
with  vessels  in  bones  and  in  the  scalp,  with  viens  at  the  root  of  the 
neck,  and  with  the  cranial  sinuses;  infection  of  the  vascular  walls; 
increased  blood  pressure  from  plethora,  inflammation,  congestion, 
restlessness,  cardiac  stimulants,  transfusion,  or  the  introduction  of  salt 
solution  into  the  circulatory  apparatus;  diminished  coagulability  of 
the  blood  the  result  of  the  ingestion  of  ammonia,  acid  fruit  juices,  or 
large  quantities  of  water,  inhalation  of  oxygen,  restriction  of  food  or 
lime  salts,  vegetarian  diet,  smoking  tobacco,  hyperthyroidism,  leech 
bite,  or  the  injection  of  hirudin  (leech  extract) ;  or  to  motion  of  the 
part,  which  may  prevent  the  formation  of,  or  dislodge  a  clot. 

Accelerated  hemostasis  may  be  due  to  a  long  narrow  wound  in  the 
perivascular  tissues;  a  contused  or  lacerated  wound  of  a  vessel,  which 
increases  contraction  and  retraction;  atheroma,  owing  to  the  small 
calibre  of  the  vessel  and  the  roughened  intima;  decreased  blood 
pressure,  particularly  that  due  to  shock  or  hemorrhage;  increased 
coagulability  of  the  blood  the  result  of  asphyxia,  hypothyroidism, 
the  puerperium;  certain  forms  of  anemia  (distinctly  that  due  to 
hemorrhage) ;  the  ingestion  of  large  quantities  of  milk,  small  quanti- 
ties of  w^ater,  or  the  medicaments  listed  below  in  the  paragraph  on 
styptics;  or  to  immobility  of  the  injured  part. 

The  diagnosis  of  hemorrhage  is  attended  with  difficulty  only 
when  the  bleeding  is  internal;  it  is  then  most  Hkely  to  be  mistaken 
for  shock  (q.v). 


3IO  MANUAL   OF    SURGERY 

The  treatment  of  hemorrhage  is  constitutional  and  local.  The 
constitutional  treatment,  which  is  that  of  shock  (q.v.),  should  be 
instituted  while  measures  are  being  taken  to  control  the  bleeding, 
and  not  before,  because  of  the  danger  of  increasing  the  loss  of  blood. 
The  local  treatment  embraces  (i)  cold,  (2)  heat,  (3)  elevation,  (4) 
styptics,  (5)  compression,  (6)  acupressure,  (7)  forcipressure,  (8) 
torsion,  (9)  ligation,  and  (10)  suture  of  the  vessel. 

1 .  Cold  in  the  form  of  ice,  cold  water,  or  evaporating  lotions  will 
hasten  the  arrest  of  hemorrhage  from  small  vessels,  but  should  not 
be  used  in  open  wounds,  because  of  the  danger  of  sepsis.  Exposure 
of  a  wound  to  air  facilitates  coagulation  partly  as  the  result  of  the 
lowered  temperature.  The  ice  bag  is  frequently  employed  in 
internal  hemorrhages  not  suitable  for  operation. 

2.  Heat  in  the  form  of  hot  water  (120°  to  150°  F.)  is  sometimes 
useful  as  a  hemostatic;  it,  like  cold,  stimulates  the  muscular  fibers  of 
the  vessels  to  contract.  Warm  water  relaxes  these  libers  and  encour- 
ages bleeding.  The  actual  cautery  should  rarely  be  employed,  as  it 
causes  sloughing,  which  interferes  with  the  healing,  and  predisposes 
to  secondary  hemorrhage.  When  used,  it  should  be  at  a  dull  red 
heat;  if  bright  red  it  cuts  like  a  knife  and  does  not  stop  bleeding. 
Electrohemo stasis,  in  which  the  tissues  to  be  divided  during  an  opera- 
tion are  crushed  with  special  forceps  and  baked  with  an  electric 
current,  possesses  no  advantages  over  the  ligature. 

3.  Elevation  alone  may  stop  hemorrhage  from  the  larger  veins; 
it  is  especially  applicable  in  bleeding  from  the  extremities. 

4.  Styptics,  such  as  antipyrin,  Monsel's  solution  (cotton  contain- 
ing Monsel's  salt  is  called  styptic  cotton),  alcohol,  turpentine,  tannic 
or  gaUic  acid,  silver  nitrate,  alum,  sodium  chlorid,  vinegar,  chlorid  of 
zinc,  and  tincture  of  matico,  are  seldom  applied  to  a  wound  by  the  sur- 
geon, as  most  of  them  produce  a  tough  coagulum  which  interferes  with 
healing.  Adrenalin  chlorid,  however,  contracts  the  vessels,  and  is  fre- 
quently employed,  particularly  in  bleeding  from  mucous  membranes. 
It  may  be  applied  by  a  swab  or  as  a  spray  in  the  strength  of  from  i 
to  1,000  to  I  to  10,000.  At  least  one  case  of  poisoning  has 
resulted  from  its  use  locally;  when  administered  internally  for  a  long 
time  it  is  said  to  cause  arteriosclerosis.  Gelatin,  5  to  10  per  cent.,  in 
normal  salt  solution  {Carnot's  solution),  has  been  used  locally  as  a 
hemostatic;  reference  has  already  been  made  to  the  importance  of 
having  it  absolutely  sterile  and  to  its  use  internally.  Among  the 
other  agents  which  increase  the  coagulability  of  the  blood,  or  con- 
tract the  vessels,  when  taken  internally,  are  turpentine,  oil  of  erigeron, 
stypticin,  cephalin,  magensium  carbonate,  opium,  dilute  sulphuric 


VASCULAR   SYSTEM  311 

acid, acetate  of  lead,  ergot,  hamamelis,  pituitrin,  and  chlorid  of  cal- 
cium. Chlorid  of  calcium,  gr.  x,  t.i.d.,  is  frequently  employed  to 
increase  the  coagulability  of  the  blood  previous  to  operation  incases  of 
chronic  jaundice.  The  injection  of  alien  blood  serum  or  transfusion 
of  blood  is  of  particular  value  in  hemophilia  (q.v.).  Kocher  and 
Fonio  suggest  coagulin  as  a  hemostatic  agent.  It  is  a  grayish  powder 
made  from  the  blood  platelets  of  animals,  and  can  be  dusted  on 
wounds,  or  used  in  a  solution;  in  the  latter  instance  the  fluid  may  be 
boiled  for  one  or  two  minutes  for  the  purpose  of  sterihzation,  and  can 
be  injected  intravenously.  Radiotherapy  and  electrolysis  are 
sometimes  employed  to  check  uterine  bleeding. 

(5)  Compression  may  be  direct  or  indirect,  i.e.,  upon  the  ends  of 
the  divided  vessel,  or  upon  the  vessel  some  distance  from  the 
wound. 

Direct  compression  may  be  made  with  the  fingers,  or  with  tamp- 
ons, compresses,  or  pads.  The  ultimate  principle  of  all  hemostatic 
agents  is,  of  course,  pressure  in  some  form.  Direct  digital  compression 
will  control  the  most  violent  hemorrhage  from  any  part  of  the 
circulatory  apparatus,  and  is  to  be  employed  in  an  emergency  until 
more  permanent  hemostasis  can  be  secured.  Capillary  hemorrhage, 
or  a  general  oozing  from  small  arterioles  and  venules,  is  quickly 
checked  by  the  pressure  of  aseptic  gauze  which  has  been  steeped 
in  hot  water.  Firm  gauze  packing  will  control  any  venous  and  many 
forms  of  arterial  bleeding.  The  graduated  compress,  which  is  made 
of  layers  of  gauze  successively  increasing  in  size  from  below  upwards, 
so  as  to  form  an  inverted  pyramid  or  cone,  was  at  one  time  used  to 
control  arterial  hemorrhage  in  regions  in  which  incisions  to  expose 
the  wounded  vessels,  e.g.,  the  palmar  arches,  might  injure  important 
structures.  The  pressure  exerted  on  oozing  points  by  the  apposition 
of  a  wound  with  sutures  or  sterile  adhesive  strips  is  frequently 
sufficient  to  control  bleeding,  especially  when  such  pressure  is 
reinforced  by  a  firm  bandage.  Bleeding  from  hone  may  be  controlled 
by  plugging  the  openings  with  antiseptic  wax,  catgut,  filaments  of 
gauze,  pieces  of  crushed  muscle,  or  fragments  of  bone  produced  by 
striking  the  bone  with  the  blunt  end  of  a  chisel;  a  large  canal  may  be 
filled  with  a  bit  of  sterilized  wood.  In  the  rectum  pressure  may  be 
made  by  introducing  and  inflating  a  rubber  bag,  e.g.,  the  colpeurynter. 
The  shirted  cannula  {cannula  a  chemise)  is  used  after  lithotomy,  to 
make  pressure  and  maintain  drainage  (Fig.  1 20) ;  the  shirted  portion 
is  stuffed  with  gauze,  In  bleeding  from  a  tooth  socket  the  cavity  may 
be  packed  with  gauze  containing  an  astringent,  and  the  pressure  aug- 
mented by  bandaging  the  jaws  tightly  shut.     In  the  urethra  pressure 


312 


MANUAL    OF    SURGERY 


may  be  effected  by  inserting  a  large  sound,  or  in  the  deep  urethra  by 
compressing  the  perineum.  In  oozing  from  the  brain  small  particles 
of  the  temporal  muscle  may  be  plastered  on  the  bleeding  points; 
this  not  only  obstructs  the  orifices  of  the  vessels  but  probably  has 
also  a  styptic  effect;  the  same  principle  may  be 
used  elsewhere.  Wounds  of  parenchymatous 
organs  in  the  abdomen  have  been  covered  with 
a  free  transplant  of  fascia,  or  stuffed  with 
omentum,  muscle,  or  fat,  held  in  place  with 
sutures.  Other  forms  of  direct  pressure,  viz. 
acupressure,  forcipressure,  ligation,  etc.,  are 
dealt  with  later.  Indirect  pressure  is  employed 
chiefly  to  control  bleeding  until  more  permanent 
measures  can  be  applied,  or  to  prevent  hemor- 
rhage during  operations.  In  the  limbs  a  tourni- 
quet (Fig.  i2i),  applied  above  the  wound,  is 
the  most  reliable  procedure;  in  an  emergency 
a  belt,  a  pair  of  suspenders,  or  a  handkerchief 
may  be  tied  about  the  limb,  and  tightened  by 
pushing  a  stick  beneath  the  band  and  twisting 
it.  A  tourniquet  should  be  applied  above  the 
elbow  or  knee,  as  the  vessels  in  the  forearm  and  leg  are  protected 
by  bones  and  not  so  readily  compressed.  The  dangers  of  the  tourni- 
quet, which  are  greater  when  the  tourniquet  is  applied  to  the  arm 
than  when  applied  to  the  thigh,  are  injury  to  the  nerves  and  soft 


Fig.    120.— Catheter  a 
chemise.      (Heath.) 


121. — Esmarch  band 


Fig.   122. 


— Petit's  tourniquet  apphed 
to  the  brachial. 


tissues,  especially  if  the  limb  is  moved  about;  contusion  or  rupture 
of  the  artery,  particularly  in  atheroma ;  and  gangrene  if  the  touriquet 
is  left  in  place  for  several  hours.  A  disadvantage  is  the  increased 
oozing  of  blood  following  the  removal  of  the  tourniquet.     In  opera- 


VASCULAR    SYSTEM  313 

tions  the  vessel  may  be  compressed  at  a  distance  by  a  clani]),  tape, 
or  the  fingers  of  an  assistant.  Forced  flexion  is  seldom  em})l()ycd  at 
the  present  time;  a  pad  is  i)laced  in  the  popliteal  space,  groin,  or 
bend  of  the  elbow,  and  the  liml)  secured  in  strong  flexion  by  means 
of  a  bandage.  Indirect  digital  compression,  although  lacking  the  dis- 
advantages of  the  tourniquet,  calls  for  a  strong,  skilled  hand  and,  if 
pressure  must  be  continued  for  a  long  time,  relays  of  assistants.  The 
common  cartoid,  the  vertebral,  and  the  inferior  thyroid  arteries  may 
be  compressed  against  the  transverse  process  of  the  sixth  cervical 
yertehm  (C/iassaignac's  tubercle)  at  the  anterior  margin  of  the  sterno- 
mastoid ;  the  facial,  against  the  lower  jaw  just  in  front  of  the  masseter ; 
the  labial  and  coronary,  by  grasping  the  lip  at  the  angle  of  the  mouth 
between  the  fingers;  the  temporal,  against  the  zygoma  immediately 
in  front  of  the  ear;  the  occipital,  against  the  skull  about  midway 
between  the  mastoid  process  and  the  external  occipital  protuberance; 
the  subclavian,  against  the  first  rib,  by  the  thumb,  or  by  the  padded 
handle  of  a  door  key,  pressed  downward,  backward,  and  inward 
just  behind  the  clavicle  and  to  the  outer  side  of  the  sternomastoid ; 
the  axillary,  against  the  head  of  the  humerus  at  the  inner  border  of 
the  coraco-brachialis,  with  the  arm  raised  to  a  right  angle;  the 
brachial,  against  the  humerus  at  the  inner  edge  of  the  biceps;  the 
radial,  at  the  wrist,  just  outside  of  the  flexor  carpi  radialis;  the  ulnar, 
in  the  same  situation,  just  outside  of  the  flexor  carpi  ulnaris;  the 
abdominal  aorta,  if  the  patient  is  not  too  stout,  against  the  vertebrae 
on  a  level  with  and  just  to  the  left  of  the  umbilicus;  the  external 
iliac,  against  the  brim  of  the  pelvis,  above  the  middle  of  Poupart's 
ligament;  the coTumon femoral,  immediately  below  Poupart's  ligament 
by  pressing  upwards  and  backwards  midway  between  the  symphysis 
pubis  and  the  anterior  superior  spine  of  the  ilium;  the  popliteal, 
against  the  femur  a  trifle  to  the  inner  side  of  the  middle  of  the 
popliteal  space;  the  anterior  tibial,  midway  between  the  two  malleoli; 
the  posterior  tibial,  half  an  inch  behind  the  tip  of  the  internal  mal- 
leolus. When  there  is  danger  of  secondary  hemorrhage,  the  point 
for  compression  may  be  marked  with  ink  or  iodin,  so  that,  in  the 
event  of  bleeding,  the  nurse  may  press  on  the  right  spot  at  once. 
It  is  much  better,  however,  in  such  cases,  to  apply  an  Esmarch  band 
loosely  to  the  limb;  if  hemorrhage  occurs  the  band  can  then  be 
tightened  without  regard  to  the  situation  of  the  artery. 

(6)  Acupressure  is  rarely  employed,  (i)  A  long  needle  may 
be  pushed  into  the  tissues,  then  over  the  vessel,  and  again  into  the 
tissues,  in  the  same  way  that  one  fastens  a  flower  to  the  lapel  of  a 
coat;  (2)  the  needle  may  be  passed  into  the  tissues  on  one  side  of 


314  MANUAL   OF    SURGERY 

the  vessel,  twisted  180°,  and  reinserted  into  the  tissues;  or  (3)  the 
needle  may  be  thrust  under  the  vessel,  and  wire  or  silk  passed  over 
the  ends  of  the  needle  in  a  ligure-of-8  fashion. 

(7)  Forcipressure,  or  the  crushing  of  the  end  of  the  vessel  with 
hemostatic  forceps,  is  frequently  employed  with  very  small  vessels, 
thus,  many  of  the  little  bleeding  points  caught  with  hemostatic 
forceps  during  an  operation  require  no  further  attention  after  the 
forceps  have  been  removed  at  the  end  of  the  operation.  When 
ligation  is  very  difficult  and  the  vessel  large,  the  forceps  may  be 
left  in  place  for  twenty-four  or  forty-eight  hours,  being,  of  course, 
protected  with  sterile  dressings.  Forcipressure  before  ligating  en 
masse  renders  bleeding  from  shrinkage  of  the  tissues  much  less 
likely  to  occur.  Very  powerful  forceps  (vasotribe,  or  angiotrihe)  are 
sometimes  used  for  this  purpose,  and  some  surgeons  do  not  even 
ligate  after  removing  the  instrument. 

(8)  Torsion  is  useful  in  certain  plastic  operations  where  the 
presence  of  knotted  ligatures  is  undesirable.  It  should  not  be  used 
in  cases  of  atheroma.  Free  torsion  is  the  twisting  of  a  vessel  several 
times  after  the  application  of  hemostatic  forceps;  it  is  used  chiefly 
for  small  vessels.  Larger  vessels  are  occluded  by  limited  torsion]  the 
artery  is  drawn  from  its  sheath  with  a  pair  of  forceps,  grasped  close 
to  the  tissues  with  a  second  pair,  then  twisted  with  the  first  forceps. 
Torsion  ruptures  the  inner  and  middle  coats,  which  contract  and 
curl  up,  and  twists  the  outer  coat;  the  end  of  the  vessel  should  never 
be  twisted  off. 

(9)  Ligation  is  the  method  of  choice  when  dealing  with  vessels 
large  enough  to  be  seen  by  the  naked  eye.  Catgut  is  the  material 
usually  employed,  although  with  very  large  arteries  or  with  thick 
pedicles  many  surgeons  prefer  silk.  Ligation  may  be  total,  or 
circumferential,  when  the  vessel  is  occluded  by  the  ligature,  or 
lateral  when  a  wound  in  the  side  of  a  vessel  is  closed  without  inter- 
rupting the  circulation.  A  circumferential  ligature  is  applied  to  the 
bleeding  end  of  a  vessel  {terminal  ligation),  or  to  the  vessel  some 
distance  from  the  wound  {ligation  in  continuity,  p.  319).  In  the 
former  the  end  of  the  vessel  is  seized  with  hemostatic  forceps,  drawn 
a  little  from  its  sheath,  when  such  exists,  and  the  ligature  tied  above 
the  forceps  in  a  reef  knot.  If  catgut  is  used,  a  third  knot  always 
should  be  added.  As  it  is  difficult  to  catch  small  vessels  without 
including  a  little  of  the  surrounding  tissue,  the  forceps  should  be 
removed  as  the  first  knot  is  tightened,  otherwise  the  ligature  may  slip 
off  when  the  forceps  are  removed.  A  suture-ligature  (Fig.  123)  is 
one  passed  through  the  tissues  about  an  artery  by  means  of  a  needle. 


VASCULAR    SYSTEM  315 

It  is  used  in  dense  tissues  from  which  the  vessel  cannot  be  drawn; 
in  necrotic  tissues  and  in  atheroma  in  order  to  prevent  cutting 
through  of  the  ligature;  in  tissues  like  the  dura,  mesentery,  and 
omentum;  and  in  any  region  in  which  there  is  danger  of  slipping 
of  the  ligature.  A  lateral  ligature  is  one  applied  to  the  side  of  a 
vessel,  generally  a  vein,  after  the  edges  of  the  wound  have  been 
drawn  up  in  the  form  of  a  cone  with  hemostatic  forceps  (Fig.  124). 
In  order  to  insure  against  slipping  the  ligature  may,  by  means  of  a 
fine  needle,  be  passed  through  ^the  venous  wall  on  each  side  of  the 
forceps.  The  efects  of  a  ligature,  when  it  is  tied  tightly,  are  rupture 
of  the  inner  and  middle  coats,  which  retract  and  invert,  and  the 
formation  of  a  small  thrombus,  which  is  finally  replaced  by  fibrous 
tissue.  Atheromatous  arteries  and  very  large  arteries,  e.g.,  the 
subclavian  and  iliac,  should  be  tied  only  firmly  enough  to  approxi- 
mate the  walls,  without  rupturing  the  intima,  else  the  ligature  may 

cut  through,  or  the  vessel  may  dilate 
and  rupture  immediately  proximal  to 
the  point  of  ligation;  some  surgeons 
apply  this  rule  to  all  vessels.     The  liga- 


PiG.  123. — Suture-ligature.  Fig.  124. — Lateral  ligature. 

(Esmarch  and  Kowalzig.)  (Esmarch  and  Kcwalzig.) 

ture  itself  is  encapsulated  if  of  non-absorbable  material.  The  liga- 
tion of  a  large  artery  causes  a  rise  in  the  general  blood  pressure, 
which  gradually  falls  as  the  collateral  circulation  is  established. 

(10)  Suture  of  blood  vessels  (angiorrhaphy)  is  the  ideal  method 
of  dealing  with  wounds  of  arteries  whose  ligation  might  lead  to 
gangrene  or  other  serious  disturbance  in  the  parts  which  they  supply, 
e.g.,  the  common  carotid,  axillary,  brachial,  aorta,  external  iliac, 
femoral,  popliteal,  and  large  abdominal  arteries.  If,  after  the 
principal  artery  of  a  limb  has  been  wounded,  the  limb  is  cold  and 
pale,  the  peripheral  end  of  the  artery  does  not  bleed,  and  congestion 
below  the  wound  does  not  follow  compression  of  the  chief  vein,  the 
collateral  circulation  is  probably  incompetent  to  maintain  the  life 
of  the  limb,  and  ar tenorrhaphy  is  mandatory  (other  methods  for 
testing  the  colateral  circulation  will  be  found  in  the  section  on 
"Amputations").  The  danger  of  tearing  out  of  the  sutures,  even 
in  the  presence  of  atheroma,  is  no  greater  than  that  of  cutting 
through  of  a  ligature,  and  if  thrombosis  occurs,  the  clot  may  form 


3l6  MANUAL   OF    SURGERY 

slowly  enough  to  allow  the  collateral  vessels  to  dilate,  a  distinct 
advantage  over  ligation.  Although  occlusion  of  the  main  veins 
of  the  limbs  is  usually  followed  by  nothing  worse  than  edema, 
gangrene  may  result  if  the  collateral  vessels  are  diseased  or  injured, 
if  the  circulation  is  sluggish  from  cardiac  or  pulmonary  derangement, 
or  if  the  vitality  of  the  part  is  impaired  by  debilitating  maladies, 
hence  suture  should  be  preferred  to  ligation.  In  wounds  of  the 
superior  mesenteric,  portal,  vena  cava  above  the  origin  of  the  renals, 
and  both  internal  jugulars,  suture  must  be  chosen,  as  ligation  gener- 
ally ends  in  death.  The  technic  of  angiorrhaphy,  which  includes 
arteriorrhaphy  (suture  of  arteries)  and  phlehorrhaphy  (suture  of  veins) 
is  as  follows :  After  controlling  the  circulation  by  the  application  of 
a  tourniquet,  or  by  compressing  the  vessel  above  and  below  the 
wound  between  the  fingers  of  an  assistant  or  by  rubber-coated 
clamps,  the  sheath  is  pushed  back,  but  no  farther  than  is  absolutely 
necessary,  and  the  edges  of  the  wound,  if  lacerated,  made  smooth 
with  a  sharp  knife;  scissors  produce  too  much  bruising.  The  sutures 
should  be  of  fine  silk,  threaded  on  the  finest  needle,  and  sterilized  by 
boihng  in  vaselin,  as  suggested  by  Carrel,  who  applies  vaselin  also 
to  the  margins  of  the  wound  to  prevent  drying.  In  a  lateral  wound 
the  operation  may  be  facilitated  by  passing  a  guide  suture,  to  be 
held  by  an  assistant,  through  each  end  of  the  wound.  The  con- 
tinuous suture  is  more  rapid  and  less  apt  to  permit  leakage  between 
the  points  of  insertion  than  the  interrupted.  The  suture  should 
penetrate  all  of  the  coats  of  the  vessel,  and  slightly  evert  the  margins 
of  the  wound  so  as  to  bring  intima  in  contact  with  intima,  the  points 
of  insertion  being  about  one  milhmeter  apart.  The  blood  current 
is  now  slowly  turned  on,  pressure  being  applied  to  the  suture  line 
until  the  stitch  holes  cease  to  bleed.  The  sheath  is  then  sutured, 
then  the  fascia,  then  the  skin.  If  more  than  one-third  of  the  cir- 
cumference of  the  vessel  is  cut,  the  section  should  be  completed  and 
an  end-to-end  anastomosis  performed.  Although  various  forms  of 
special  apparatus  may  be  used  for  this  purpose,  the  best  method  is 
that  of  Carrel.  After  cutting  the  ends  of  the  vessel  square  across 
and  trimming  away  any  of  the  external  coat  which  prolapses  into 
the  lumen,  three  guide  sutures  are  passed  through  both  ends  of  the 
vessel  at  points  equidistant  around  the  circumference,  which,  by 
traction  on  these  sutures,  is  transformed  into  a  triangle,  whose  sides, 
after  being  elongated  as  much  as  the  elasticity  of  the  vessel  permits, 
thus  preventing  stricture,  are  sutured  with  a  continuous  suture 
(Fig.  125).  The  author  has  successfully  sutured  the  axillary  artery 
in  four  instances,  the  abdominal  aorta  in  one,  the  common  carotid 


VASCULAR    SYSTEM 


317 


in  one,  the  radial  in  one,  the  femoral  in  five,  and  the  popliteal  in  one' 
five  of  these  being  end  to  end  anastomoses. 

Resume. — The  treatment  of  alarming  hemorrhage  from  any 
open  icound  is,  first,  the  immediate  control  of  bleeding  by  the  appli- 
cation of  digital  pressure  to  the  vessels  in  the  wound;  then,  in  the 
extremities,  the  application  of  a  tourniquet  above  the  wound. 
Nothing  further  should  be  done  until  the  patient  has  reacted  from 
shock,  when  the  parts  may  be  carefully  disinfected  and  the  vessels 
ligated,  enlarging  the  wound  as  much  as  may  be  necessary,  and 
remembering  that  both  ends  of  large  arteries  and  veins  should  be 
tied,  and  that,  if  the  wound  is  a  lateral  one,  the  vessel  must  be  Hgated 
above  and  below  the  w;ound  and  severed  between  the  ligatures,  thus 
permitting  retraction  and  contraction.  The  desirabihty  of  suturing 
important  vessels  instead  of  occluding  them  by  ligation,  should  be 
borne  in  mind.  A  general  oozing  which 
seemingly  comes  from  no  particular  point 
is  controlled  by  firm  gauze  packing,  or  by 
suture  of  the  wound  and  the  application  of 
a  firm  bandage.  An  artery  capable  of 
producing  vigorous  bleeding  must  be  lig- 
ated in  the  wound,  though  even  an  opera- 
tion is  necessary  for  such  purpose.  Liga- 
tion in  continuity  for  hemorrhage  should 
be  performed  only  under  very  exceptional 
circumstances,  as  it  is  often  ineffectual, 
owing  to  a  free  collateral  circulation;  if 
the  collateral  circulation  is  poor,  there  is 
danger  of  gangrene  or,  in  the  case  of  the 
common  carotid,  paralysis  and  death;  again  the  bleeding  vessel  may 
be  a  large  vein,  or  an  artery  not  derived  from  the  vessel  ligated. 
Possibly  in  cases  in  which  the  tissues  are  rotten  from  infection,  or 
in  which  packing  fails  to  control  permanently  a  bleeding  artery 
whose  exposure  would  necessitate  the  destruction  of  important 
structures,  ligation  in  continuity  may  be  indicated.  In  the  former 
instance  recurrence  of  bleeding  would  call  for  amputation.  In  re- 
gions such  as  the  neck  where  elastic  constriction  is  impracticable, 
digital  compression  must  be  maintained  until  the  wound  has  been 
sufficiently  enlarged  to  secure  the  vessel  with  hemostatic  forceps. 
The  patient  may  then  be  brought  out  of  the  shock,  and  the  hemor- 
rhage controlled  as  outlined  above.  Dangerous  hemorrhage  in  the 
chest  or  abdomen  is  treated,  after  opening  these  cavities,  by  ligation, 
suture,  gauze  packing,  or,  in  rare  instances,  by  the  cautery;  often  an 


Fig. 


-Carrel's  technic  for 


anastomosis  of  blood  vessels. 


3l8  MANUAL    OF    SURGERY 

important  organ,  e.g.,  spleen,  kidney,  or  uterus,  must  be  removed. 
In  these  cases  the  surgeon  must  operate  immediately,  in  the  pre- 
sence of  even  the  most  profound  shock.  Hemorrhage  into  the  cra- 
nium or  spinal  canal  is  dangerous,  not  from  the  loss  of  blood,  but 
from  the  pressure  exerted  upon  the  central  nervous  system;  it  is 
controlled,  alter  trephining  or  laminectomy,  by  ligation  or  packing. 
The  treatment  ot  serious  bleeding  into  the  subcutaneous  tissues,  in- 
cluding diffuse  traumatic  aneurysm,  is  immediate  digital  pressure  on 
the  main  artery  above,  until  a  tourniquet  can  be  applied;  after  the 
patient  has  reacted  from  shock,  the  bleeding  vessel  is  exposed  by 
incision  and  ligated  or  sutured.  Serious  bleeding  from  arterioles, 
venules,  or  capillaries  is  dealt  with  under  "Hemophilia." 

Hemophilia  {hemorrhagic  diathesis)  is  a  congenital  and  hereditary 
tendency  to  excessive  bleeding,  arising  spontaneously,  or  from 
wounds  of  even  the  most  trivial  character.  The  cause  is  not  known. 
It  is  far  more  frequent  in  males  than  in  females,  but  females  are  much 
more  Hable  to  transmit  the  disease  to  their  offspring;  indeed  a  female 
belonging  to  a  bleeder  family,  but  who  is  not  herself  subject  to  the 
affection,  is  likely  to  beget  bleeder  children,  especially  if  they  be 
males.  About  50  per  cent,  of  those  with  hemophilia  die  before  the 
tenth  year,  and  only  10  per  cent,  reach  maturity.  The  presence  of 
hemophilia,  which  may  be  suspected  from  the  history  and  con- 
firmed by  estimating  the  coagulation  time  of  the  blood,  contrain- 
dicates  all  but  the  most  urgent  operations  (see  also  "Spontaneous 
Hemorrhage"). 

The  treatment  consists  in  the  internal  administration  of  tonics  and 
the  careful  avoidance  of  all  forms  of  injury;  even  the  most  trivial 
operations,  like  vaccination  or  circumcision,  must  be  regarded  as 
highly  dangerous.  In  the  presence  of  bleeding  ergot,  acetate  of 
lead,  gelatin,  calcium  lactate,  or  calcium  chlorid  may  be  given  inter- 
nally. Thyroid  extract  has  been  recommended,  although,  according 
to  Kocher,  hyperthyroidism  is  accompanied  by  a  decrease  in  the 
coagulability  of  the  blood.  Adrenalin  or  Carnot's  solution  and  pro- 
longed pressure  with  elevation  are  used  locally.  The  application  of 
coagulin,  or  of  clotting  blood  from  a  healthy  individual  may  be 
tried.  The  most  effective  measure  is  the  transfusion  of  normal 
blood.  If  this  is  not  done  one  may  inject  10  to  20  c.c.  of  normal 
horse  serum  into  a  vein,  or  20  to  40  c.c.  beneath  the  skin;  antidiph- 
theritic  serum  also  has  been  used  in  hemophilia  and  other  hemor- 
rhagic diseases.  Escharotics  or  the  actual  cautery  may  temporarily 
check  the  oozing,  but  it  is  very  Hkely  to  recur  with  the  separation  of 
the  sloughs.     Petechise  and  ecchymoses  require  no  local  treatment; 


VASCULAR    SYSTEM  319 

hematomata  and  hem  arthroses  should  be  protected  from  injury  and 
never  opened. 

LIGATION  OF  ARTERIES  IN  CONTINUITY 

The  indications  for  ligation  in  continuity  are  aneurysm,  arterial 
hemorrhage  under  the  circumstances  mentioned  above,  malignant 
growths  whose  progress  may  be  hindered  by  shutting  off  the  blood 
supply,  and  operations  on  very  vascular  structures  in  order  to  reduce 
the  loss  of  blood.  In  addition  may  be  mentioned  the  very  doubtful 
indications  of  enlarged  prostate,  for  which  the  internal  ihacs  have 
been  tied,  trigeminal  neuralgia,  for  which  the  carotid  has  been  tied, 
and  epilejjsy,  for  which  the  vertebral  has  been  tied.  In  cases  in 
which  the  necessity  for  ligation  is  not  pressing,  the  state  of  the 
collateral  circulation  may  be  determined  before  operation  by  the 
Matas  method  (see  "Indications  for  Amputation,"  chap.  xxxi). 
If  the  collateral  circulation  is  inadequate  it  may  be  rendered  more 
active  by  intermittent  compression  of  the  artery,  or  by  partly  oc- 
cluding the  artery  with  a  band  of  aluminium  (Halsted)  or  fascia,  and 
completing  the  ligation  after  a  week  or  ten  days.  Chromicized 
catgut  should  be  used  for  all  but  the  largest  vessels,  for  which  floss 
silk  is  the  best  material. 

The  operation  is  preceded  by  mapping  out  the  course  of  the 
vessel  by  an  imaginary  line.  The  skin  and  fascia  are  then  divided 
along  this  line,  important  structures  drawn  aside,  and  the  vessel 
located  by  means  of  anatomical  guides,  e.g.,  a  muscle,  a  bony  promi- 
nence, a  nerve,  or  another  vessel.  The  artery  itself  is  recognized  by 
its  pinkish  color,  the  thickness  of  its  walls,  and  by  pulsation,  the 
veins  being  dark  in  color,  thin  walled,  and  non-pulsating.  The 
arteries  of  the  upper  extremity,  the  leg,  and  most  of  the  smaller 
arteries  of  the  trunk  have  venae  comites;  those  of  the  thigh,  the  head, 
and  the  neck,  except  the  lingual,  have  but  one  companion  vein. 
Pressure  upon  the  vessels  will  distend  the  vein,  collapse  the  artery, 
and  obliterate  the  pulse  below  the  point  of  pressure.  The  anatom- 
ical guides,  however,  are  more  reliable  than  the  indi\ddual  features 
of  the  artery,  as  even  pulsation  may  be  transmitted  to  the  vein,  or  be 
absent  in  the  artery  as  the  result  of  pressure  or  hemorrhage.  The 
sheath  of  the  artery  is  opened  for  about  half  an  inch  by  Hf ting  it  from 
the  artery  with  forceps,  and  incising  just  beneath  the  forceps  with 
the  flat  of  the  knife  towards  the  artery  (Fig.  126  A).  The  sheath  is 
then  held  by  forceps,  and  separated  from  the  artery  by  an  aneurysm 
needle  armed  with  the  ligature,  which  is  carried  around  the  vessel,  in 


320 


MANUAL   OF    SURGERY 


C. 


the  direction  away  from  the  most  important  neighboring  structure, 
which  is  usually  the  vein  (Fig.  1 26  B) .  The  ligature  is  then  tied  in  a 
reef  knot  by  placing  the  ends  of  the  thumbs  or  index  fingers  upon  the 
knot,  and  separating  them  by  using  the  middle  joint  as  the  basis  of 
support  (Fig.  126  C).     The  second  knot  should  be  tied  firmly,  but 

should  not  be  jerked,  as  such  may 
break  the  hgature;  a  third  knot 
always  should  be  added  when  cat- 
gut is  employed.  With  the  smaller 
arteries  the  ligature  may  be  tied 
with  sufficient  firmness  to  rupture 
the  inner  coats.  With  very  large 
arteries  this  may  result  in  the 
cutting  through  of  the  ligature,  or 
in  dilatation  and  rupture  immedi- 
ately proximal  to  the  ligature  In 
these  vessels  the  walls  should  be 
approximated  only,  the  stay  knot 
being  employed  (Fig.  127).  The 
principal  dangers  following  liga- 
tion in  continuity  are  secondary 
hemorrhage  and  gangrene. 
The  innominate  artery  has  been  tied  forty-three  times  with  seven 
recoveries,  the  chief  causes  of  death  being  sepsis,  secondary  hemor- 
rhage, and  cerebral  lesions.  An  incision  is  carried  for  three  or  four 
inches  along  the  anterior  margin  of  the  right  sternomastoid  to  the 
episternal  notch,  then  outward  along  the  upper  margin  of  the  inner 
third  of  the  clavicle,  severing  the  skin, 
platysma,  and  the  superficial  and  deep 
fasciae.  The  sternohyoid,  sterno- 
thyroid, and  inner  edge  of  the  sterno- 
mastoid are  divided  and  retracted. 
The  anterior  jugular  vein  is  severed 
between  two  ligatures,  the  carotid 
sheath  opened,  and  the  carotid  artery 
followed  to  the  bifurcation  of  the  in- 
nominate. Resection  of  the  sterno- 
clavicular articulation  may  be  necessary  to  expose  the  vessel  pro- 
perly. The  inferior  thyroid  veins  are  tied  or  drawn  aside,  the  right 
internal  jugular  and  right  innominate  vein  are  pushed  to  the  right, 
and  the  left  innominate  vein  is  displaced  downwards.  A  strongly 
curved  aneurysm  needle  is  passed  from  without  and  below,  upwards 


Fig.  126. — A.  Opening  the  sheath. 
Drawing  ligature  round  the  artery. 
Tying  artery.      (MouUin.) 


Fig. 


127. — Stay  knot.     (Balance  and 
Edmunds.) 


VASCULAR    SYSTEM 


321 


and  inwards,  care  being  taken  not  to  injure  the  pneumogastric  nerve 
and  pleura,  which  He  to  the  right.  The  ligature  should  be  of  floss 
silk,  tied  in  a  stay  knot. 

The  common  carotid  arises  from  the  innominate  on  the  right,  from 
the  arch  of  the  aorta  on  the  left.  The  line  of  the  artery  is  from  the 
sternoclavicular  articulation  to  midway  between  the  angle  of  the 
jaw  and  the  tip  of  the  mastoid,  the  vessel  bifurcating  at  the  upper 
border  of  the  thyroid  cartilage.  Whenever  possible  the  vessel  is  tied 
above  the  anterior  belly  of  the  omohyoid,  i.e.,  in  the  superior  carotid 
triangle,  or  the  triangle  of  election,  as  here  the  vessel  is  more  super- 
ficial and  the  operation  less  difi&cult.     The  triangle  of  election  is 


Fig.   128. — Ligature  of  the  common  carotid  and  facial  arteries.      (Moullin.) 

bounded  above  by  the  posterior  belly  of  the  digastric,  behind  by  the 
sternomastoid,  and  in  front  by  the  anterior  belly  of  the  omohyoid. 
The  inferior  carotid  triangle,  called  the  triangle  of  necessity  because 
the  vessel  is  tied  here  only  when  absolutely  necessary,  is  bounded 
above  by  the  anterior  belly  of  the  omohyoid,  below  by  the  sterno- 
mastoid, and  in  front  by  the  median  line.  Ligation  in  the  triangle  of 
election  (Fig.  128)  is  carried  out  with  a  sand  pillow  beneath  the 
neck,  the  head  turned  towards  the  opposite  side,  and  the  chin  raised. 
A  three  inch  incision,  the  center  of  which  is  on  a  level  with  the 
cricoid  cartilage,  is  made  along  the  arterial  line,  severing  the  skin, 
and  both  layers  of  the  superficial  fascia,  between  which  lies    the 


322  MANUAL   OF    SURGERY 

platysma,  and  exposing  the  anterior  edge  of  the  sternomastoid, 
which  is  the  muscular  guide  to  the  artery.  After  cutting  the  deep 
fascia  which  is  attached  to  the  border  of  the  sternomastoid,  this 
muscle  is  retracted  outwards,  the  omohyoid  drawn  downwards,  and 
the  costal  process  of  the  sixth  cervical  vertebra  (carotid  tubercle  of 
Chassaignac) ,  which  Hes  immediately  under  the  artery  at  the  point 
where  it  is  crossed  by  the  omohyoid,  felt  with  the  finger.  The 
sheath  of  the  vessel  is  identified  by  means  of  the  descendens  noni 
nerve,  which  descends  upon  it,  and  opened  on  the  inner  side  to  avoid 
the  internal  jugular  vein,  which  lies  to  the  outer  side  in  a  separate 
compartment.  The  pneumogastric  nerve  lies  behind  and  between 
the  artery  and  vein,  in  a  separate  compartment  of  the  same  sheath. 
The  needle  is  passed  from  without  inwards.  Ligation  in  the  triangle 
of  necessity  (Fig.  128)  is  performed  by  making  a  three  inch  incision 
downward  along  the  arterial  line  from  the  level  of  the  cricoid 
cartilage.  The  sternomastoid  is  drawn  outwards,  the  sterno- 
hyoid and  sternothyroid  inwards,  the  omohyoid  upwards.  The 
sheath  is  opened  on  the  inner  side  and  the  operation  completed  as 
described  above.  The  inferior  thyroid  veins  may  be  tied  it  they  are 
in  the  way;  in  the  lower  part  of  the  neck  the  anterior  jugular,  and  on 
the  left  side,  the  internal  jugular,  lie  in  front  of  the  artery  and  must 
be  carefully  retracted.  The  recurrent  laryngeal  nerve  and  the 
inferior  thyroid  artery  are  on  a  deeper  plane  and  should  not  be 
encountered.  Ligation  of  the  ccmmon  carotid,  in  one-fourth  of  the 
cases,  results  in  cerebral  complications,  which  may  be  immediate, 
such  as  collapse  from  cerebral  anemia,  or  which  take  the  form  of 
cerebral  soitening,  causing  hemiplegia.  One-half  of  those  developing 
intracranial  trouble  die. 

The  internal  carotid  is  rarely  ligated.  The  line  of  the  artery  is 
parallel  with  and  a  trifle  external  (not  internal  as  one  would  suspect 
from  the  name)  tc  that  of  the  external  carotid.  The  muscular  guide 
is  the  sternomastoid,  and  the  incision  that  for  the  external  carotid. 
The  sternomastoid  is  retracted  backwards,  the  posterior  belly  of  the 
digastric  upwards,  and  the  external  carotid  forwards.  The  needle  is 
passed  from  without  inwards,  avoiding  the  internal  jugular  vein,  the 
pneumogastric  nerve,  the  cervical  sympathetic  nerve,  and  the  ascend- 
ing pharyngeal  artery. 

The  external  carotid  extends  from  the  bifurcation  of  the  common 
carotid,  on  a  level  with  the  superior  border  of  the  thyroid  cartilage, 
to  midway  between  the  external  auditory  meatus  and  the  condyle  of 
the  lower  jaw.  The  line  of  the  artery  is  the  upper  portion  of  that  for 
the  common  carotid,  the  muscular  guide  the  sternomastoid,  and  the 


VASCULAR    SYSTEM 


323 


position  of  the  patient  that  for  h'gation  of  the  common  carotid.  A 
three  inch  incision,  with  the  center  at  the  great  cornu  of  the  hyoid 
bone,  is  made  along  the  arterial  line,  severing  the  skin,  both  layers  of 
the  superficial  fascia,  which  includes  the  platysma,  and  the  deep 
fascia.  The  sternomastoid  is  retracted  outwards,  the  posterior 
belly  of  the  digastric  and  the  stylohyoid  upwards,  and  the  hypo- 
glossal nerve  inwards.  The  point  of  election  for  ligation  is  opposite 
to  the  tip  of  the  great  cornu  of  the  hyoid  bone,  and  between  the 
superior  thyroid  and  lingual  arteries.  The  superior  thyroid,  lingual 
and  facial  veins,  which  lie  in  front  of  the  artery,  should  be  avoided, 
and  any  lymphatic  glands  which  are  in  the  way  removed.  The 
needle  is  passed  from  without  inward,  carefully  avoiding  the  superior 


Fig.  129. — Ligature  of  subclavian  and  lingual  arteries.     (Moullin.) 

laryngeal  nerve,  which  lies  behind  the  artery.  The  artery  is  distin- 
guished from  the  common  carotid  and  from  the  internal  carotid  by 
the  presence  of  branches. 

The  superior  th5T:oid  arises  from  the  external  carotid  close  to  its 
origin,  passes  upwards  and  inwards,  then  downwards  and  forwards  to 
the  thyroid  gland.  A  two  inch  incision,  with  its  center  on  a  level 
with  the  upper  edge  of  the  thyroid  cartilage,  is  made  along  the 
carotid  line,  and  the  external  carotid  exposed.  The  artery  is  then 
tied,  care  being  taken  to  avoid  the  superior  thyroid  veins  and  the 
superior  laryngeal  nerve. 

The  lingual  artery  (Fig.  129)  may  be  tied  close  to  its  origin 
through  the  incision  for  the  exposure  of  the  external  carotid,  or  under 


324 


MANUAL   OF    SURGERY 


the  hyoglossus  in  the  submaxillary  triangle.  In  the  latter  operation 
the  patient  is  placed  in  the  same  position  as  that  for  the  ligation  of  the 
carotid.  A  curved  incision,  with  its  center  opposite  the  greater 
cornu  of  the  hyoid  bone,  is  made  from  below  and  external  to  the 
symphysis  menti,  to  below  and  within  the  point  where  the  anterior 

edge  of  the  masseter  joins  the  lower 
border  of  the  jaw,  severing  the  skin, 
both  layers  of  the  superficial  fascia,  and 
the  platysma.  The  submaxillary  gland, 
which  lies  in  a  compartment  of  the  deep 
fascia,  is  retracted  upwards  after  severing 
the  deep  fascia,  thus  exposing  the  two 
bellies  of  the  digastric,  the  posterior  edge 
of  the  mylohyoid,  and  the  hyoglossus. 
The  digastric  tendon  is  retracted  down- 
wards, and  the  hypoglossal  nerve  (the  guide 
to  the  artery)  and  the  ranine  vein,  which 
cross  the  hyoglossus,  are  pushed  upwards; 
the  hyoglossus  is  divided  transversely 
between  the  nerve  and  the  hyoid  bone. 
The  artery  lies  immediately  beneath  the 
muscle  on  the  middle  constrictor  of  the 
pharynx,  and  is  tied  by  passing  the  needle 
from  above  downwards. 

The  facial  artery  (Fig.  128)  maybe 
tied  through  the  incision  for  ligation  of 
the  external  carotid,  or  at  the  point  where 
it  crosses  the  lower  border  of  the  jaw  im- 
mediately in  front  of  the  masseter,  by 
making  a  small  transverse  incision  through 
the  skin,  platysma,  and  fascia.  The 
needle  is  passed  from  behind  forwards,  to 
avoid  the  vein,  which  lies  behind. 

The  temporal  artery  may  be  tied  in 
front  of  the  auditory  meatus  at  the  point 
where  it  crosses  the  zygoma.  A  small 
vertical  incision  is  made  through  the  skin 
and  fascia,  between  the  tragus  and  the  condyle  of  the  jaw,  and  the 
vessel  tied  just  above  the  root  of  the  zygoma,  avoiding  the  auriculo- 
temporal nerve  and  branches  of  the  temporo-facial  portion  of  the 
seventh  nerve. 

The  occipital  artery  may  be  tied  at  its  origin,  through  the  incision 


Fig.  130.- — Diagram  to  show 
the  collateral  circulation  after 
ligature  of  common  carotid,  sub- 
clavian, and  axillary  arteries. 
A.  Common  carotid.  B.  Internal 
carotid.  C.  External  carotid. 
D.  Vertebral.  E.  Circle  of  Willis. 
P.  Basilar.  G.  Subclavian.  H. 
Thyroid  axis.  I.  Inferior  thyroid. 
J.  Superior  thyroid.  K.  Occipital. 
L.  Princeps  cervicis.  M.  Deep 
cervical.  N.  Transversalis  colli. 
O.  Suprascapular.  P.  Posterior 
scapular.  Q.  Dorsalis  scapulae. 
R.  Infrascapular.  S.  Subscap- 
ular. T.  Long  thoracic.  U. 
Short  thoracic.  V.  Superior  in- 
tercostal. X.  Internal  mam- 
mary. Y.  and  Z.  Aortic  inter- 
costals.      ("Walsham.) 


VASCULAR    SYSTEM  325 

made  for  the  external  carotid,  or  behind  the  mastoid  process.  In 
the  latter  operation  an  incision  is  made  from  the  tip  of  the  mastoid 
upwards  and  backwards  towards  the  occipital  protuberance.  The 
posterior  fibers  of  the  sternomastoid,  the  splenius,  and  the  trachelo- 
mastoid  are  severed,  and  the  vessel  tied  between  the  mastoid  process 
and  the  transverse  process  of  the  atlas. 

The  subclavian  artery  (Fig.  129)  arises  from  the  innominate  on 
the  right,  and  the  arch  of  the  aorta  on  the  left,  and  extends  from  the 
sternocla\'icular  joint  to  the  lower  border  of  the  first  rib.  It  is 
divided  into  three  parts  by  the  scalenus  anticus,  the  first  portion 
lying  to  the  inner  side  of  the  muscle,  the  second  behind,  and  the 
third  to  the  outer  side.  The  third  portion  lies  in  the  subclavian 
triangle,  which  is  formed  by  the  clavicle  below,  the  posterior  belly 
of  the  omohyoid  on  the  outer  side,  and  the  posterior  border  of  the 
sternomastoid  on  the  inner  side.  Ligation  of  the  first  or  second 
portion  is  very  rarely  performed.  The  line  of  the  third  portion  is 
from  the  posterior  border  of  the  sternomastoid  to  the  anterior  border 
of  the  trapezius,  half  an  inch  above  and  parallel  to  the  clavicle.  The 
muscular  guide  is  the  outer  border  of  the  scalenus  anticus,  which  lies 
approximately  behind  the  outer  border  of  the  sternomastoid.  The 
bony  guide  is  the  tubercle  on  the  first  rib  into  which  the  scalenus 
anticus  is  inserted,  the  artery  lying  directly  behind  it.  In  ligation 
of  the  third  part  of  the  artery  the  thorax  is  raised,  the  neck  extended, 
and  the  head  turned  to  the  opposite  side.  The  size  of  the  subclavian 
triangle  is  increased  by  pulling  down  the  arm,  and  fixing  it  in  this 
position  by  pushing  the  forearm  under  the  back.  An  incision  is  made 
over  the  claxacle,  from  the  outer  margin  of  the  sternomastoid  to  the 
inner  margin  of  the  trapezius,  after  the  skin  has  been  drawn  down. 
This  maneuver  protects  the  external  jugular  vein,  and  when  the 
skin  is  released  leaves  the  wound  half  an  inch  above  the  clavicle. 
The  incision  involves  the  skin,  superficial  fascia  and  platysma,  and 
the  deep  fascia.  The  external  jugular  vein  is  retracted  inward  or 
divided  between  two  ligatures,  the  posterior  belly  of  the  omohyoid 
retracted  upwards,  and  the  scalenus  anticus  with  the  tubercle  on  the 
first  rib  identified.  The  transverse  cervical  and  the  suprascapular 
arteries  should  not  be  injured,  as  they  assist  in  the  collateral  circula- 
tion. The  subclavian  vein  lies  in  front  of  and  below  the  finger  as  it 
rests  on  the  scalene  tubercle;  the  artery  lies  behind  and  can  be  felt 
pulsating  on  the  first  rib.  The  brachial  plexus  lies  above  and  to  the 
outside,  the  lower  cord  passing  behind  the  vessel.  With  the  finger 
guarding  the  vein,  the  needle  is  passed  from  above  downwards  close 
to  the  artery,  to  avoid  the  lowest  cord  of  the  plexus.  There  is  also 
some  danger  of  wounding  the  pleura. 


326  MANUAL    OF    SURGERY 

The  internal  mammary  artery  courses  downwards  on  the  inner 
surface  of  the  chest  wall,  about  half  an  inch  from  the  edge  of  the 
sternum.  It  may  be  tied  after  dividing  the  intercostal  structures 
outwards  from  the  edge  of  the  sternum  for  an  inch  or  more.  In 
order  to  secure  both  ends  of  a  divided  internal  mammarj',  which  is 
absolutely  necessary  owing  to  the  freedom  of  the  collateral  circula- 
tion, a  portion  of  the  costal  cartilage  may  be  resected. 

The  vertebral  artery  has  been  tied  for  wounds,  secondary  hemor- 
rhage following  ligature  of  the  innominate,  and  for  epilepsy.  An 
incision  dividing  the  skin,  superficial  fascia,  platysma,  and  deep 
fascia,  is  made  along  the  lower  half  of  the  posterior  border  of  the 
sternomastoid.  This  muscle  is  retracted  forwards  with  the  external 
jugular  vein  and  the  scalenus  anticus,  upon  which  lie  the  phrenic 
nerve  and  the  transverse  cervical  artery.  The  transverse  process  of 
the  sixth  cervical  vertebra  is  defined,  and  the  artery  found  below  this 
point  in  the  interval  between  the  scalenus  anticus  and  the  longus 
colli.  The  vein  lies  superficial  to  the  artery  and  is  drawn  to  the  outer 
side,  the  needle  being  passed  from  without  inwards,  care  being  taken 
to  avoid  the  pleura  and  the  thoracic  duct. 

The  inferior  thyroid  may  be  tied  through  the  incision  made  for 
ligation  of  the  common  carotid  in  the  triangle  of  necessity.  The 
sternomastoid  and  the  carotid  sheath  are  drawn  outwards,  the  omo- 
hyoid upwards,  and  the  sternohyoid  and  sternothyroid  divided  if 
necessary.  The  artery  is  found  below  the  transverse  process  of  the 
sixth  cervical  vertebra  and  behind  the  carotid  sheath.  Care  should 
be  taken  not  to  injure  the  middle  cervical  ganglion,  the  recurrent 
laryngeal  nerve,  the  esophagus,  or,  low  down  in  the  neck,  the  thoracic 
duct. 

The  axillary  artery  extends  from  the  lower  border  of  the  first  rib  to 
the  lower  border  of  the  tendon  of  the  teres  major.  It  is  divided  into 
three  portions  by  the  pectoralis  minor,  the  first  portion  being  above 
the  second  behind,  and  the  third  below  that  muscle.  The  line  of  the 
artery  is  f  f  om  the  middle  of  the  cla\'icle  to  the  junction  of  the  anterior 
and  middle  thirds  of  the  outlet  of  the  axilla.  The  second  portion  of 
the  artery  is  not  tied,  owing  to  its  depth  and  to  the  fact  that  it  is 
closely  surrounded  by  large  nerve  trunks.  Ligation  of  the  first 
portion  may  be  accomplished  through  an  incision  from  the  coracoid 
process  of  the  scapula  to  within  one  inch  of  the  sternoclavicular 
joint,  parallel  with  and  half  an  inch  below  the  clavicle.  After 
di\'iding  the  superficial  structures,  the  clavicular  portion  of  the  pecto- 
ralis major  is  severed  and  the  costocoracoid  membrane  incised  below 
the  subclavius.     The  acromiothoracic  artery  and  cephalic  vein  are 


VASCULAR    SYSTEM 


327 


avoided,  the  pectoralis  minor  drawn  downwards,  and  the  needle 
passed  from  below  upwards  to  avoid  the  vein,  which  is  below  and  to 
the  inner  side,  while  the  finger  guards  the  brachial  plexus,  which  lies 
above  and  to  the  outer  side.  In  ligation  of  the  third  portion  (Fig. 
131)  the  arm  is  abducted,  and  a  three  inch  incision  made  along  the 
inner  border  of  the  coracohrachialis,  dividing  the  skin  and  fascia?. 
The  median  nerve  lies  on  the  artery  and,  with  the  musculocutaneous 
nerve,  which  is  more  external,  is  drawn  outwards.  The  axillary 
vein  and  the  ulnar  and  internal  cutaneous  nerves,  which  lie  to  the 
inner  side,  are  separated,  and  the  ligature  passed  from  within  out- 
wards. Ligation  of  the  termination  of  the  axillary  or  the  beginning 
of  the  brachial,  i.e.,  between  the  circumflex  and  the  superior  profunda 
arteries  is  more  dangerous  than  above  or  below  these  points,  since 
there  exists  only  one  small  collateral  branch  running  f  romi  the  poste- 
rior circumflex  to  the  superior  profunda. 


f'^rrr/'a  h-neMaile  m/aclf- 


W.cefis   muscle 


me-rye 


Pig.   131. — Ligature  of  axillary 
artery.      (MouUin.) 


Ji££dian.  iieri>'e 


Fig.  132. — Ligature  of  brachial 
artery.     (Moullin.) 


The  brachial  artery  underlies  a  line  drawn  from  the  junction  of 
the  anterior  with  the  middle  third  of  the  outlet  of  the  axifla,  to  a 
point  midway  between  the  two  condyles  of  the  humerus.  The 
muscular  guide  is  the  inner  border  of  the  biceps.  Ligation  at  the 
middle  of  the  arm  (Fig.  132)  is  conducted  with  the  arm  ab- 
ducted and  the  forearm  supinated.  There  should  be  no  support 
beneath  the  arm  for  fear  that  the  soft  structures  might  be  pushed 
forwards  over  the  artery  and  so  comphcate  the  operation.  An 
incision  two  or  three  inches  long  is  made  along  the  inner  border  of 
the  biceps,  severing  the  skin  and  fasciae.  The  muscle  is  retracted 
outwards  and  the  median  nerve,  which  at  the  middle  of  the  arm 
crosses  the  artery  from  without  inwards,  located.  The  nerve  is 
displaced  to  the  more  convenient  side,  and  the  needle  passed  from  it, 
after  separating  the  venae  comites  and,  above  the  middle  of  the  arm, 


328  MANUAL    OF    SURGERY 

the  basilic  vein,  which  here  Hes  beneath  the  deep  fascia  and  close  to 
the  artery.  The  ulnar  nerve  lies  to  the  inside.  At  the  bend  of  the 
elbow  the  biceps  tendon  is  the  guide.  A  two  inch  incision  is  made  along 
the  inner  edge  of  the  biceps  tendon  extending  down  to  the  crease  of 
the  elbow.  The  median  basilic  vein  is  drawn  downwards  and  in- 
wards, the  bicipital  fascia  incised,  the  venae  comites  separated,  and 
the  ligature  passed  from  within  outwards  to  avoid  the  median  nerve. 
The  ulnar  artery  curves  from  its  point  of  origin  about  one  inch 
below  the  bend  of  the  elbow,  to  the  ulnar  side  of  the  forearm,  thence 
passes  downward  to  the  radial  side  of  the  pisiform  bone.  The  line 
of  the  upper  third  is  from  the  middle  of  the  front  of  the  elbow  joint 
to  the  junction  of  the  upper  and  middle  thirds  of  the  ulna.  The  line 
of  the  lower  two-thirds  is  from  the  apex  of  the  internal  condyle  of  the 
humerous  to  the  radial  side  of  the  pisiform  bone.  The  muscular 
guide  is  the  outer  border  of  the  flexor  carpi  ulnaris.  Ligation  at  the 
wrist  (Fig.  133)  is  accomplished  by  making  an  incision  an  inch  or 

more  in  length  along  the  radial  border  of 
Bcrfifaseia  ^^vq  flexor  carpi  ulnaris,  which  is  drawn 

inwards  after  the  deep  fascia  has  been 
opened.  The  ligature  is  passed  from 
within  outwards  to  avoid  the  ulnar  nerve, 
which  lies  to  the  ulnar  side  of  the  artery. 
Ligation  of  the  middle  third  is  performed 
by  making  a  three  inch  incision  in  the 
Fig.  133.— Ligature  of  the  radial  line   of    the    vcsscl,    dividing    the    deep 

and  ulnar  arteries.      (MouUin.)  .  •  ^         n 

fascia,  and  separatmg  the  nexor  carpi 
ulnaris  from  the  flexor  sublimis  digitorum;  this  interspace  is  marked 
by  a  whitish  or  yellowish  line,  which  is  often  indistinct  and  sometimes 
absent,  but  may  always  be  distinguished  by  moving  the  wrist  and 
the  fingers. 

The  radial  artery  underMes  a  line  drawn  from  midway  between 
the  tips  of  the  condyles  of  the  humerus,  to  the  ulnar  side  of  the  sty- 
loid process  of  the  radius.  The  muscular  guide  is  the  inner  border  of 
the  supinator  longus.  For  ligation  in  the  upper  third  make  a  three 
inch  incision  along  the  line  of  the  vessel,  divide  the  fasciae,  retract 
the  supinator  longus  outwards,  and  pass  the  needle  from  without 
inwards.  The  radial  nerve  lies  to  the  radial  side  of  the  vessel.  For 
ligation  above  the  wrist  (Fig.  133)  an  incision  is  made  in  the  line  of 
the  vessel,  the  fasciae  divided,  and  the  vessel  found  between  the 
supinator  longus  and  the  flexor  carpi  radiahs.  In  this  situation  the 
radial  nerve  lies  on  the  dorsum  of  the  forearm  and  is  not  encountered. 
A  small  superficial  vein  may  overlie  the  artery,  and  branches  of  the 


VASCULAR    SYSTKM 


329 


external  cutaneous  nerve  may  be  seen.     At  the  back  of  the  wrist,  or 

in  la  tahatiere  (snuff  box),  which  is  bounded  internally  by  the  tendon 

of  the  extensor  primi  internodii,   and  externally  by  the  extensor 

secundi  internodii  pollicis,  the  line  of  the  artery  is  from  the  tip  of  the 

styloid  process,  to  the  posterior  angle  of  the  first 

interosseous  space.     An  incision  is  made  between 

the  tendons,  from  the  styloid  process  to  the  base 

of  the  first  metacarpal  bone.     Beneath  the  skin 

will  be  found   the  superficial  radial  vein  and  a 

few   branches    of   the  radial   nerve.     The   deep 

fascia  is  then  opened  and  the  artery  exposed. 

The  abdominal  aorta  has  been  tied  15  times 
with  15  deaths,  although  one  patient  lived  10 
days,  one  39  days,  and  one  48  days.  The  opera- 
tion is  performed  by  opening  the  abdomen  in 
the  median  line,  retracting  the  intestines,  incising 
the  posterior  parietal  peritoneum,  and  tying  the 
vessel. 

The  common  iliac  artery  extends  from  the 
aorta,  opposite  the  left  side  of  the  body  of  the 
fourth  lumbar  vertebra,  for  two  inches,  to  the 
upper  end  of  the  sacroiliac  synchondrosis.  The 
line  of  the  arterv  is  the  upper  two  inches  of  a 

'  .  brachial,     radial,      and 

hne  drawn  from  a  point  half  an  inch  below  and  ulnar  arteries,  a.  Bra- 
to  the  left  of  the  umbilicus,  to  midway  between  ui?a;;D:  Su^'perS'pro: 
the  anterior  superior  spine  of  the  ilium  and  the  funda;  e.  inferior  pro- 

,        .  ,  .  ,_,  ,  ,  .11         funda;  F.  Anastomotica 

symphysis  pubis.  Ihe  vessel  may  be  tied  by  magna;  G.  Radial  re- 
the    transperitoneal   or    by   the   retroperitoneal  current;  H.  interosseous 

^  _  -^  ^  recurrent;     I.    Anterior 

"route.  The  transperitoneal  route  is  preferable,  and  k.  Posterior  ulnar 
The  abdomen  is  opened  through  the  left  rectus  L.^^c^o^mmon  interos- 
muscle  bv  an  incision  whose  center  is  a  Kttle  ^^0^^=  ^^-  Posterior  in- 

'  .  .  terosseous;  X.  Anterior 

below  the  umbilicus.  The  intestines  are  pushed  interosseous;  00. 
aside,  the  posterior  parietal  peritoneum  opened,.  tZt'^^^eZ'^X'^r 
and  the  needle  passed  from  the  patient's  right  arch;   Q.    Superficial 

,,  ii'i  -111  -i-         palmar  arch,  R.  Poster- 

to  let t.  on  both  Sides  ot  the  body,  as  the  vein  lies  ior  circumflex;  s.  Sub- 
behind  the  artery  on  the  right  side,  and  behind  scapular.  (Waisham.; 
and  internal  to  it  on  the  left.  In  the  retroperitoneal  metJwd  an  in- 
cision is  made  from  just  above  the  internal  abdominal  ring,  above 
and  parallel  to  Poupart's  ligament,  curving  upwards  as  the  outer 
end  of  this  structure  is  reached,  to  near  the  tip  of  the  cartilage  of  the 
eleventh  rib.  The  abdominal  muscles  and  the  transversahs  fascia 
are  divided,  and  the  unopened  peritoneum  pushed  upwards  and  in- 


PlG.  134. — Diagram 
to  show  the  collateral 
circulation  after  liga- 
ture   of    the     axillary. 


33^ 


MANUAL    OF    SURGERY 


wards.  The  ureter  crosses  the  artery  but  usually  adheres  to  the 
peritoneum  and  is  carried  out  of  harm's  way  with  it.  The  deep 
muscular  guide  is  the  inner  border  of  the  psoas  magnus  muscle.  The 
ligature  is  passed  as  in  the  previous  operation. 

The  internal  iliac  may  be  tied  extraperitoneally  or  transperi- 
toneally  through  the  incisions  given  for  the  common  iliac. 

The  gluteal  artery  emerges  from  the  pelvis  through  the  upper  part 
of  the  great  sacrosciatic  foramen,  at  the  junction  of  the  upper  and 
middle  thirds  of  a  line  drawn  from  the  posterior  superior  spine  of  the 
ilium  to  the  top  of  the  great  trochanter.  An  incision  is  made  along 
this  line,  the  libers  of  the  gluteus   maximus   separated,    the   deep 


^erttencam. 


SarCeriua  muscle/ 


Fig.   135.- 


-Ligature  of  external  iliac  and  superficial  femoral  arteries.     In  this  figure  the 
incision  for  the  femoral  artery  is  placed  too  low.      (Moullin.) 


fascia  opened,  and  the  artery  exposed  by  separating  the  gluteus 
medius  from  the  pyriformis.  The  sciatic  and  internal  pudic  arteries 
may  be  reached  through  an  incision  parallel  with,  but  one  and  one- 
half  inches  lower  than  that  used  for  the  gluteal  artery.  The  libers 
of  the  gluteus  maximus  are  separated,  and  the  vessels  found  emerg- 
ing from  the  lower  part  of  the  great  sacrosciatic  foramen,  at  the 
lower  border  of  the  pyriformis  and  just  below  the  great  sciatic 
nerve. 

The  external  iliac  artery  underlies  the  lower  two-thirds  of  a  line 
drawn  from  one-half  inch  below  and  to  the  left  of  the  umbilicus,  to 
midway  between  the  anterior  superior  spine  of  the  ilium  and  the 


VASCULAR    SYSTEM  33  I 

sNinphysis  pubis.  The  artery  may  he  tied  hy  the  transperitoneal 
method  through  an  incision  in  the  middle  h"ne  or  in  the  semilunar  line. 
The  extraperitoneal  method  (Fig.  135)  is  performed  through  an  incision 
about  four  inches  in  length,  extending  from  one-half  inch  above  the 
middle  of  Poupart's  ligament,  to  a  point  one  inch  above  and  one 
inch  internal  to  the  anterior  superior  iliac  spine.  After  dividing  the 
skin,  superficial  fascia,  and  external  oblique,  internal  obliciue,  and 
transversalis  muscles,  the  transversalis  fascia  is  cautiously  opened  and 
the  peritoneum  pushed  upwards  and  inwards  until  the  psoas  muscle 
along  the  inner  border  of  which  the  vessel  runs,  has  been  exposed. 
The  needle  is  passed  from  within  outwards  to  avoid  the  vein.  One 
should  be  careful  not  to  injure  the  epigastric  or  the  circumflex  artery, 
as  they  are  important  aids  in  establishing  the  collateral  circulation. 
The  line  of  the  femoral  artery  is  from  midway  between  the 
anterior  superior  spine  of  the  ilium  and  the  symphysis  pubis,  to 
the  inner  condyle  of  the  femur.  The  muscular  guide  is  the  sartorius, 
which  lies  external  to  the  vessel  in  the  upper  third,  in  front  in  the 
middle  third,  and  to  the  inner  side  in  the  lower  third.  The  artery 
may  be  ligated  just  below  Poupart's  ligament,  at  the  apex  of  Scarpa's 
triangle,  or  in  Hunter's  canal.  Ligation  of  the  common  femoral 
just  below  Poupart's  ligament  is  rarely  performed,  because  its  num- 
erous branches  may  interfere  with  perfect  occlusion,  and  the  col- 
lateral circulation  is  much  more  free  after  ligation  of  the  external 
iliac.  An  incision  through  the  skin  and  superficial  fascia  is  made  in 
the  line  of  the  artery,  from  a  httle  above  Poupart's  ligament  down- 
wards, for  two  or  three  inches.  The  superficial  veins  and  the  lymp- 
hatic glands  are  drawn  aside,  the  fascia  lata  divided,  and  the  sheath 
opened.  The  needle  is  passed  from  within  outwards  to  avoid  the 
vein.  The  anterior  crural  nerve  lies  to  the  outer  side.  For  ligation 
of  the  superficial  femoral  at  the  apex  of  Scarpa's  triangle  (Fig. 
136)  an  incision  four  inches  in  length,  the  center  of  which  is 
four  inches  below  Poupart's  ligament,  is  made  along  the  arterial 
line,  dividing  the  skin  and  fasciae.  The  sartorius  is  retracted  out- 
wards, and  the  needle  passed  from  within  outwards  to  avoid  the 
vein,  which  in  this  situation  lies  to  the  inner  side  of  and  behind  the 
artery.  The  internal  cutaneous  nerve  lies  in  front  of  the  vessel,  and 
the  long  saphenous  nerve  lies  to  the  outer  side  on  a  deeper  plane. 
For  Ugation  in  Hunter's  canal  a  four  inch  incision  is  made  in  the 
line  of  the  artery  in  the  middle  third  of  the  thigh.  After  dividing 
the  fascia  lata  the  sartorius  is  retracted  inwards,  the  fibrous  roof  of 
Hunter's  canal,  running  from  the  abductor  longus  to  the  vastus 
internus,  incised,  and  the  sheath  of  the  vessel  exposed.     The  long 


332 


MANUAL    OF    SURGERY 


saphenous  nerve  lies  upon  the  sheath  and  should  be  drawn  out  of 
the  way.  The  needle  is  passed  from  without 
inwards  to  avoid  the  femoral  vein,  which  lies 
behind  and  slightly  to  the  outer  side. 

The  popliteal  artery  should  rarely  be  liga- 
ted,  since  gangrene  of  the  leg  follows  in  about 
one-half  of  the  cases  The  artery  extends 
from  the  lower  end  of  Hunter's  canal,  at  the 
junction  of  the  middle  and  lower  thirds  of  the 
thigh  to  the  lower  border  of  the  popliteus 
muscle.  The  line  of  the  vessel  is  from  a  point 
one  inch  internal  to  the  upper  angle  of  the 
popliteal  space,  passing  midway  between  the 
condyles  of  the  femur,  to  the  apex  of  the  lower 
angle  of  the  space.  The  muscular  guide  in  the 
upper  third  is  the  inner  border  of  the  semi- 
membranosus; in  the  lower  part  the  vessel  lies 
midway  between  the  heads  of  the  gastrocne- 
mius. The  internal  pophteal  nerve  is  super- 
ficial to  the  artery,  and  the  vein  is  external 
above,  but  crosses  the  vessels  lower  down, 
lying  between  the  artery  and  the  internal 
popliteal  nerve.  The  external  popliteal  nerve 
Hes  well  to  the  outer  side.  In  ligation  of  the 
the'^coiiatltaT^lrSio^n  ^PP^^  third  an  incisiou  four  inches  in  length  is 
after  ligature  of  the  com-  made  along  the  outcr  border  of  the  semimem- 

mon  iliac,  external  and  in-    ,  ,  .    ,     .  ,      ,    .  i        ii        • 

ternai  iliac,  femoral,  popii-  branosus,  which  IS  retracted  mwards,  the  m- 
teai,  and  arteries  of  the  leg.  temal   popHtcal    ncrvc    displaced    outwards, 

A.   Common  iliac;   B.   Ex-  -^     ^ 

ternai  iliac;  c.  Internal  and  the  needle  passcd  from  without  inwards, 
nk,4uSba^r!  P.  ESgSrk;  ^s  in  this  situation  the  vein  is  slightly  external. 
G.    Circvimflex   iliac;    H.  Tj^g   lower   part   of   the   vessel  may  be  tied 

Obturator;    I.    Gluteal;    J.  ,  .       ,    .  .  i       i         j 

Lateral  sacral;  K.  Sciatic;  through  an  mcisiou  midway  between  the  heads 
ko'?rdT;'N."int"rtr^^  c^:  ^^  ^he  gastrocnemius,  which  are  separated  while 
guarding  the  saphenous  vein  from  harm.  The 
vein  and  nerve  are  drawn  to  the  inner  side, 
tica  magna;  s  s.  Superior  ^^^  ^^g  needle  passcd  froni  within  outwards. 

articular;     T    T.     Inferior 

articular;  u.  Tibial  recur-  The  postcrlor  tibial  artery  is  marked  by  a 
Anteriol'  tibiai^^''?'  p^l  ^^'^^  ^^^^  the  Center  of  the  popliteal  space,  to 
terior  tibial;  Y.  Peroneal,  a  point  a  finger's  breadth  behind  the  internal 

(Walsham.)  .         .  •  j  ji         /•    .1       i 

malleolus.    Ligation  in  the  middle  of  the  leg 

(Fig.  137)  is  performed  with  the  leg  flexed  and  lying  on  the 
outerside.     An  incision  four  inches  long  is  made  a  fingers'  breadth 


cumflex;  O.  Femoral;  P. 
Comes  ischiatici;  0  0  0, 
Perforating;  R.  Anastoma- 


VASCULAR    SYSTEM 


333 


behind  the  internal  border  of  the  tibia,  dividing  the  skin  and  super- 
ficial and  deep  fasciae,  and  avoiding  the  long  saphenous  vein  and 
nerve.  The  gastrocnemius  is  drawn  inwards,  the  soleus  and  the 
aponeurosis  on  its  under  surface  severed  and  retracted  backwards 


Fig.   137. — Ligature  of  posterior  tibial  artery.      (Moullin.) 

and  the  vessel  with  the  posterior  tibial  nerve  to  the  outer  side  ex- 
posed on  the  tibiahs  posticus.  After  separating  the  venae  comites 
the  needle  is  passed  from  without  inwards.  For  ligation  behind  the 
malleolus  make  the  incision  one  finger's  breadth  behind  the  malleolus, 


Tihialis   anticus 


^Uxtensor 
prei>is  digiterum] 
muscle 


JH^/ensor  /ofif/u.f 
digiioruhi 

Pig.  138. — Ligation  of  the  anterior 
tibial  artery.      (Moullin.) 


TenrJon  q^ 
7\/rfcnsor 
/irojuiiis 
I  /lolllcis 


Pig.   139. — Ligation  of  the  dorsalis  pedis 
artery.      (Moullin.) 


open  the  internal  annular  ligament  between  the  tendons  of  the  flexor 
longus  digitorum  and  flexor  proprius  pollicis,  and  pass  the  needle 
from  behind  forwards  thus  avoiding  the  nerve,  which  is  posterior 
and  external.  The  tendon  sheaths  should  not  be  opened,  and  the 
annular  Kgament  should  be  sutured  after  the  vessel  has  been  tied. 


334 


MANUAL   OF    SURGERY 


The  line  of  the  anterior  tibial  artery  is  from  a  point  midway 
between  the  head  of  the  fibula  and  the  outer  tuberosity  of  the  tibia, 
to  a  point  midway  between  the  two  malleoH.  The  muscular  guide 
is  the  outer  margin  of  the  tibiaUs  anticus.  For  ligation  in  the  upper 
third  of  the  leg  make  an  incision  in  the  hne  of  the  artery,  incise  the 
deep  fascia,  and  separate  the  tibiahs  anticus  from  the  extensor 
communis  digitorum.  The  artery  will  be  found  in  the  intermuscular 
space  upon  the  interosseous  membrane,  the  anterior  tibial  nerve 
lying  to  the  outer  side.  The  needle  should  be  passed  from  without 
inwards.  In  the  middle  of  the  leg  (Fig.  138)  the  same  inter- 
muscular space  is  opened,  and  the  vessel  found  between  the  tibiahs 
anticus  and  the  extensor  proprius  pollicis;  the  nerve  hes  in  front  of 
the  artery  and  slightly  to  the  outer  side;  it  should  be  retracted 
outwards  and  the  needle  passed  from  without  inwards.  In  the  lower 
third  of  the  leg  an  incision  is  made  in  the  line  of  the  artery  along  the 
external  border  of  the  tendon  of  the  tibiahs  anticus.  After  dividing 
the  deep  fascia  separate  the  tibialis  anticus  from  the  extensor 
proprius  polhcis,  retract  the  nerve,  which  hes  in  front  and  a  little 
external,  outwards,  and  pass  the  needle  from  without  inwards. 

The  line  of  the  dorsalis  pedis  is  from  the  midpoint  between  the 
malleoh,  to  the  upper  end  of  the  interosseous  space  between  the  first 
two  metatarsal  bones.  The  muscular  guide  is  the  outer  margin  of 
the  tendon  of  the  extensor  proprius  pollicis.  An  incision  is  made  in 
the  line  of  the  vessel  along  the  outer  border  of  the  extensor  proprius 
polhcis,  the  deep  fascia  opened,  the  extensor  proprius  polhcis 
retracted  inwards,  and  the  extensor  brevis  digitorum  outwards. 
Locate  the  nerve  and  pass  the  needle  from  it  (Fig.  139). 

The  line  of  the  peroneal  artery  is  from  the  posterior  border  of  the 
head  of  the  fibula,  to  the  point  where  the  outer  border  of  the  tendo- 
Achilles  is  inserted  into  the  oscalcis.  Make  an  incision  along  the 
arterial  line,  incise  or  draw  inwards  the  soleus,  which  arises  from  the 
upper  third  of  the  bone  only,  divide  the  flexor  longus  polhcis  close 
to  the  bone  and  incise  the  aponeurotic  structure  covering  the 
vessel,  which  is  found  close  to  the  fibula.  The  needle  may  be  passed 
in  either  direction  and  the  venae  comites  tied  with  the  artery. 


CHAPTER  XVI 
LYMPHATIC  SYSTEM 

Wounds  of  the  thoracic  duct  during  operations  on  the  neck  are 
probably  more  frequent  than  is  generally  believed,  but  as  there  may 
be  two  or  more  ducts,  the  accident  may  not  be  followed  by  serious 
consequences,  and  is  overlooked.  Of  thirty-one  recorded  cases, 
two  were  fatal.  The  accident  is  recognized  during  operation,  by 
the  escape  of  a  white  fluid  which  coagulates  on  standing.  In  many 
cases  the  leakage  is  not  noticed  until  several  days  later,  owing  to  the 
mixture  of  the  lymph  with  blood,  and  to  the  small  amount  of  food 
taken  immediately  after  operation.  The  quantity  of  lymph  lost 
varies;  when  the  thoracic  duct  is  not  supplemented  by  a  rich  col- 
lateral circulation,  it  may  be  two  or  more  quarts  a  day.  In  these 
cases  there  are  great  thirst,  exhaustion,  emaciation,  hunger,  and 
deficiency  or  suppression  of  urine;  the  general  condition,  owing  to 
the  dehydration,  resembling  cholera.  Wounds  or  ruptures  of  the 
thoracic  duct  lower  in  its  course  may  give  rise  to  chylous  ascites  or 
chylothorax.  The  treatment,  if  the  wound  is  recognized  at  the  time 
of  operation,  consists  of  suture  of  the  duct,  ligation,  forcipressure  or 
gauze  tamponage.  If  not  recognized  until  after  operation,  compres- 
sion with  gauze  may  be  tried,  and  faihng  in  this,  if  there  is  progres- 
sive emaciation,  reopening  of  the  wound  and  suture  or  ligature  of 
the  duct.  In  one  case  the  end  of  the  duct  was  implanted  into  the 
jugular  vein  (Deanesley). 

Lymphangiectasis,  or  dilatation  of  lymphatics,  may  be  congenital 
or  acquired. 

Congenital  lymphangiectasis  may  occur  as  varicose  lymphatics 
more  or  less  generalized  over  certain  portions  of  the  body,  or  as  a 
localized  lymphatic  dilatation  with  marked  prohferation  of  the 
connective  tissue  elements  of  the  part,  such  as  is  seen  in  macro- 
glossia,  niacrocheilia,  and  in  nevus  lymphaticus. 

Acquired  lymphangiectasis  is  the  result  of  obstruction  from  tumors 
pressing  on  the  lymph  vessels,  wounds  and  cicatrices  involving 
the  lymph  vessels,  filaria,  thrombolymphangitis,  or  chronic  inflamma- 
tion, neoplasms,  or  removal  of  lymph  glands.  Rupture  of  dilated 
lymph  vessels  is  followed  by  lymphorrhea,  causing  chyluria,  chylous 
ascites,  chylothorax,  chylous  diarrhea,  chylous  hydrocele,  etc.     Obstruc- 

335 


336  MANUAL    OF    SURGERY 

tive  lymphangiectasis  is  accompanied  by  a  solid  or  lymphatic  edema 
in  which  there  is  little  or  no  pitting  on  pressure.  This  absence 
of  pitting  on  pressure  is  due,  not  to  the  consistency  of  the  lymph, 
which  is  fluid,  but  to  the  hyperplasia,  especially  of  the  connective- 
tissue  cells,  consequent  upon  the  overnutrition.  The  skin  and 
subcutaneous  tissues  are  greatly  thickened,  the  former  presenting  a 
coarse,  corrugated  surface,  sometimes  covered  with  lymphatic 
warts,  which  may  ulcerate  and  give  rise  to  lymphatic fistulcE.  When 
the  hyperplasia  becomes  enormous  the  condition  is  called  elephan- 
tiasis; elephantiasis  Arabum,  or  true  elephantiasis,  when  due  to  the 
filaria  sanguinis  hominis;  pseudoelephantiasis,  when  the  result  of 
other  forms  of  obstruction.  Elephantiasis  Arabum  is  rarely  seen 
outside  of  the  tropics.  The  parts  most  frequently  affected  are  the 
legs  {Barhadoes  leg),  scrotum  (Fig.  140),  and  vulva.  The  part 
becomes  gigantic,  the  scrotum  sometimes  reach- 
ing the  ground.  The  filaria  sanguinis  hominis 
passes  its  intermediate  stage  in  the  body  of  the 
mosquito,  the  ova  entering  the  human  body  by 
means  of  contaminated  water,  or  possibly  di- 
rectly from  the  bite  of  a  mosquito.  The  worm 
^^^^^^^W  finally  lodges  in  the  lymphatics,  produces  ob- 
^^^^^   T  struction,  and  liberates  a  large  number  of  em- 

^^^K    '■"  bryos.     The  adult  worm  may  be  as  long   as 

^^^K^  three  inches.     The  embryos  are  about  ^^0  of 

^^^^PHh       an  inch'in  length,  and  are  found  in  the  blood  dur- 
ing the  night,  or  at  least  during  the  time  that  the 

Fig.    140. — Elephantiasis         \-       .  i       .       r  a  r    i  i 

of  scrotum.    (Nolan.)     paticuts  sclccts  tor  rcposc.     Arcas  01  lymph- 
angiectasis are  subject  to  attacks  of  inflamma- 
tion, often  associated  with  chill  and  fever  (elephantoid  fever),  and 
sometimes  eventuating  in  abscess. 

The  treatment  of  lymphatic  varix  is  excision.  Lymphedema  should 
when  possible,  be  treated  by  removing  the  cause,  e.g.,  a  tumor.  The 
excision  of  lymph  glands,  however,  may  augment  the  edema.  In  a 
few  cases  of  true  elephantiasis  the  parent  filaria  has  been  localized 
and  removed.  When  the  cause  cannot  be  removed,  and  the  trouble 
progresses  despite  elevation,  massage,  and  the  appHcation  of  an 
elastic  bandage,  operative  measures  may  be  considered.  Multiple 
punctures,  and  ligation  of  the  artery  of  supply  are  not  recom- 
mended. In  lymphedema  of  the  upper  extremity  due  to  carcinoma 
of  the  breast  and  axillary  glands  Handley  has  obtained  much  benefit 
by  passing  long  silk  threads  through  the  subcutaneous  tissues  of  the 
forearm  and  arm  to  the  subcutaneous  tissues  of  the  chest,    thus 


LYMPHATIC    SYSTEM  337 

providing  caj)illary  drains  for  the  lymph.  Kondolcon  has  secured 
good  results  in  several  cases  of  lymphedema  of  the  lower  extremity 
by  excising  long  strips  of  the  deep  fascia;  this  permits  the  subcu- 
taneous lymph  to  pass  to  the  deeper  structures,  which,  according  to 
Kondoleon,  are  normal  and  capable  of  absorbing  the  lymph.  In  the 
worst  cases  of  elephantiasis  wedge-shaped  sections  of  the  diseased 
tissues  may  be  excised,  or  the  entire  part  (scrotum,  labium,  upper  or 
lower  extremity)  may  be  amputated. 

Lymphangioma  (see  chapter  on  "Tumors")- 

Acute  lymphangitis  always  follows  infective  processes  within  the 
area  drained  by  the  inflamed  vessels.  The  walls  of  the  lymphatics 
and  generally  the  tissues  surrounding  the  vessels  take  on  the  ordinary 
changes  of  inflammation,  and  lymph  thrombosis  may  ensue.  The 
process  ends  in  resolution  or  in  suppuration.  In  the  former  instance 
recovery  may  be  only  partial,  obliteration  or  dilatation  of  the  vessels 
ensuing.  , 

The  S3miptoms  are  those  of  sepsis.  In  tubular  lymphangitis, 
in  which  the  large  lymph  vessels  alone  are  involved,  red  lines  may  be 
seen  coursing  from  the  infected  area  of  the  nearest  glands.  There  may 
or  may  not  be  tenderness  and  edema.  Confusion  with  phlebitis  (q.v.) 
is  possible.  In  rctij'orm  lymphangitis  the  capillary  lymph  vessels  are 
affected  and  the  redness  is  general;  this  condition  is  practically  the 
same  as  erysipelas.  In  either  instance  suppuration  may  be  en- 
countered, either  along  the  lymph  vessels  or  in  the  lymphatic  glands. 

The  treatment  is  primarily  the  disinfection  of  the  wound  from 
which  the  absorption  of  infection  Is  taking  place.  The  limb  should 
be  elevated  and  put  at  rest,  and  the  lymph  vessels  covered  with  an 
ointment  containing  ichthyol,  belladonna,  and  mercury.  In  the 
early  stages  cold,  and  later  heat,  may  be  of  service.  Suppuration 
demands  incision  and  drainage.  The  constitutional  treatment  is 
that  of  sepsis. 

Chronic  lymphangitis  may  follow  an  acute  attack,  or  it  may  be 
chronic  from  the 'beginning,  e.g.,  in  syphilis,  tuberculosis,  and  ele- 
phantiasis. The  treatment  is  that  of  the  cause;  in  some  instances, 
particularly  in  the  tuberculous  variety,  excision  may  be  attempted. 
Acute  lymphadenitis  is  due  to  the  same  causes  as  acute  lymphan- 
gitis, and  occasionally  follows  cold  or  injury,  inflammatory  processes 
in  contiguous  structures,  or  infection  from  the  blood  stream.  The 
lymph  vessels  may  or  may  not  participate  in  the  inflammation. 
The  glands  enlarge  as  the  result  of  the  hyperemia  and  exudation, 
and  the  surrounding  tissues  are  usually  more  or  less  involved  in  the 
process  (periadenitis) . 


338  MAXUAL    OF    SURGERY 

The  symptoms  are  those  of  fever  in  all  cut  the  mildest  cases.  The 
glands  are  tender  and  palpably  enlarged.  In  the  severer  cases  the 
overlying  skin  becomes  red.  edematous,  and  adherent,  and  the  glands 
are  welded  into  one  mass,  which  finally  softens  owing  to  the  formation 
of  pus. 

The  treatment  in  the  early  stages  is  that  ol  acute  lymphangitis. 
The  source  of  infection  is  often  of  a  trivial  nature  and  frequently 
overlooked.  A  scratch  on  the  foot  is  sufficient  to  produce  a  Je- 
moral  adenitis,  in  which  the  glands  about  the  saphenous  opening  are 
involved.  In  inguinal  adenitis,  in  which  the  glands  running  parallel 
to  Poupart's  ligament  are  inflamed,  and  to  which  the  term  bubo  is 
commonly  apphed,  the  penis,  urethra,  scrotum,  lower  part  of  the 
abdomen,  anus,  perineum,  and  buttock  should  be  carefully  examined. 
In  cervical  adenitis  the  scalp  should  be  inspected  for  conditions  like 
eczema  or  pediculosis,  the  ear  for  chronic  inflammation  or  skin 
lesions,  the  Hps  for  cracks  or  ulcers,  the  teeth  for  caries,  the  gums 
for  pyorrhea,  and  the  tongue  and  throat  for  lesions  through  which 
infection  might  gain  access.  When  suppuration  is  threatened  poul- 
tices may  be  applied,  but  pus  should  be  evacuated  as  soon  as  it 
forms. 

Chronic  lymphadenitis  follows  the  acute  form,  particularly 
when  the  source  of  irritation  has  not  been  removed ;  it  also  occurs  as 
the  result  of  chronic  infection,  particularly  by  the  infectious  granulo- 
mata,  the  most  important  of  which  are  syphilis  and  tuberculosis. 

The  diagnosis  of  the  cause  of  chronically  enlarged  glands,  which 
are  sometimes  loosely  called  lymphadenoma  or  lymphoma,  involves  a 
consideration  of  (1)  the  chronic  simple  form,  (2)  the  tuberculous  and 
(3)  the  syphiHtic  varieties,  (4)  Hodgkin's  disease,  (5)  lymphatic 
leukemia,  and  (6)  neoplasms. 

1 .  In  chronic  simple  lymphadenitis  some  source  of  continuous  irri- 
tation in  the  area  drained  by  the  lymph  glands  may  be  discovered. 
Although  the  glands  are  enlarged  and  perhaps  tender,  they  do  not 
tend  to  mat  together  or  to  suppurate.  The  treatment  consists  in  rest 
of  the  part,  remioval  of  any  source  of  infection,  the  local  application 
of  iodin,  belladonna,  mercury,  or  ichthyol,  and  the  administration 
of  tonics.  If  recovery  does  not  follow  appropriate  treatment,  a 
strong  suspicion  of  tuberclosis  should  be  entertained. 

2.  Tuberculous  lymphadenitis  is  often  painless,  progresses  despite 
local  treatment,  and  successively  involves  gland  after  gland.  The 
glands  show  a  strong  tendency  to  adhere  to  each  other  and  to  the 
skin,  and  to  undergo  caseous  degeneration.  The  condition  is  most 
common  in  children,  in  whom  other  signs  of  tuberculosis  may  be 


LYMPHATIC    SYSTEM  339 

recognized.  The  family  history  is  of  some  importance.  The  use  of 
tuberculin  for  diagnosis  is  not  generally  employed  (see  "Diagnosis  of 
Tuberculosis").  In  the  neck  tuberculous  glands  usually  make  their 
appearance  first  in  the  submaxillary  triangle.  Calcified  tuberculous 
lymph  glands  may  be  shown  by  the  X-ray.  The  treatment  is  removal 
of  the  diseased  glands,  if  possible,  and  attention  to  the  general  health 
as  in  tuberculosis  elsewhere.  Recurrence  takes  place  in  probably 
one-half  of  the  cases,  and  should  be  dealt  with  in  the  same  manner  as 
the  primary  focus.  When  complete  extirpation  is  impracticable,  as 
much  of  the  broken  down  tissue  as  possible  should  be  removed  with 
the  curette.  Encouraging  results  have  been  obtained  with  radio 
and  heliotherapy. 

3.  Syphilitic  lymphadenitis  is  diagnosticated  by  the  history  of  a 
sore,  by  associated  lesions  of  syphilis,  by  the  Wassermann  test,  and 
by  the  results  of  treatment.  The  glands  are  hard,  discrete,  not 
adherent  to  each  other  or  to  the  skin,  do  not  tend  to  suppurate,  and 
are  neither  painful  nor  tender.  The  enlargement  in  the  primary 
stage  is  confined  to  the  glands  anatomically  related  to  the  sore; 
during  the  secondary  period  the  distribution  is  general,  the  epitro- 
chlear,  the  submental,  and  post  cervical  glands  always  being  in- 
volved ;  in  the  tertiary  period  a  gland  or  a  group  of  glands  may  become 
gummatous.     The  treatment  is  that  of  syphilis. 

4.  In  Hodgkin's  disease  {pseudoleukemia,  general  lymphadenosis) 
the  enlargement  is  usually  first  noticed  at  the  root  of  the  neck,  and 
then  spreads  to  other  regions,  sometimes  involving  the  lymphatic 
structures  throughout  the  body  and  often  the  spleen.  The  glands 
increase  rapidly  in  size,  forming  enormous  masses  in  which  the  indi- 
vidual lymph  nodes  are  readily  made  out,  each  mass  resemb- 
ling a  bunch  of  large  grapes ;  there  is  little  or  no  pain  or  periadenitis, 
and  rarely  suppuration  (Fig.  141).  In  some  instances  the  disease 
remains  localized  for  a  considerable  time.  The  nature  of  the  condi- 
tion is  not  quite  clear,  some  believing  it  to  be  sarcomatous,  some 
tuberculous,  and  some  a  distinct  morbid  entity  that  is  due  to  a  bacillus 
that  can  be  recognized  by  microscopic  study  of  an  excised  gland. 
Recurring  attacks  of  intermittent  fever  are  common.  The  blood 
shows  no  characteristic  changes  beyond  those  of  a  progressive  anemia 
and  occasionally  eosinophilia.  The  disease  is  fatal  in  from  a  few 
months  to  several  years.  The  treatment,  if  the  glandular  enlargement 
is  sufficiently  localized,  is  excision;  in  other  cases  arsenic  and  radio- 
therapy. Coley's  fluid  has  been  tried,  and  Yates  uses  a  vaccin 
prepared  from  a  diphtheroid  bacillus,  which  is  believed  to  be  causa- 
tive. 


340 


MANUAL   OF    SURGERY 


5.  Lymphatic  leukemia  closely  resembles  Hodgkin's  disease,  but 
the  blood  shows  a  marked  leukocytosis;  or  a  relative  lymphocytosis, 
without  an  increase  in  the  total  number  of  white  cells.  Spleno- 
medulluary  leukemia  and  chloroma  also  may  present  enlarged 
lymph  glands.  The  treatment  of  these  conditions  is  similar  to  that  of 
Hodgkin's  disease. 

6.  Neoplasms  of  the  lymph  glands,  excluding  Hodgkin's  disease 
and  leukemia,  may  be  primary  or  secondary. 

The  primary  growths  are  (a)  lymphosarcoma,  (b)  ordinary 
sarcoma,  (c)  endothelioma. 

a.  Lymphosarcoma  arises  from  the  lymphatic  tissue  and  consists 
chiefly  of  lymphocytes,  hence  the  term  lymphocytoma.  It  differs 
from  ordinary  sarcoma  in  that  it  may  begin  in  several  glands  of  the 


Fig.   141. — Hodgkin's  disease.      (Longcope — Pennsylvania  Hospital.) 


same  region  at  the  same  time;  it  rarely  breaks  down  or  ulcerates 
through  the  skin,  although  it  infiltrates  environing  structures;  it 
metastasizes  by  the  lymphatics ;  and  when  the  tumor  cells  reach  the 
blood  stream,  possibly  through  the  thoracic  duct,  they  often  give 
rise  to  secondary  growths  in  the  lymphatic  tissue  of  the  intestine, 
a  region  in  which  metastases  from  ordinary  sarcoma  or  carcinoma 
seldom  occur.  Lymphosarcoma  grows  rapidly  and  is  quickly  fatal, 
b.  Ordinary  sarcoma  springs  from  the  connective  tissue  of  a  lymph 
gland,  and  is  composed  of  round  or  spindle  cells,  or  both,  hence  the 
clinical  course  varies  in  difit'erent  cases.  However,  the  tumor  always 
begins  in  a  single  gland,  ultimately  infiltrates  the  surrounding  struc- 
tures, ulcerates,  and  metastasizes  by  the  blood.  Sometimes  the 
affected  gland  reaches  an  enormous  size,  looking  like  a  kidney,  before 
the  neoplasm  breaks  through  the  capsule. 


LYMPHATIC    SYSTEM  341 

c.  Endothelioma  {lymphangioendothelioma)  is  derived  from  the 
endothelium  of  the  sinus  of  a  lymph  gland.  One  or  several  nodes 
may  be  involved.  The  tumor  often  grows  slowly,  recurs  locally 
after  excision,  and  does  not  metastasize  to  distant  parts  (cf.  endothe- 
lioma of  the  carotid  body  and  of  the  parotid  gland).  In  other  cases 
it  exhibits  all  the  features  of  ordinary  sarcoma. 

The  secondary  growths  are  usually  carcinomatous,  the  primary 
neoplasm  being,  or  having  been,  in  the  area  drained  by  the  affected 
glands.  Lymphosarcoma,  melanotic  sarcoma,  and  sarcoma  of  the 
tonsil,  testis,  and  thyroid  also  cause  secondary  growths  in  the  lymph 
glands. 

The  treatment  of  all  neoplasms  is,  if  possible,  excision.  Radio- 
therapy may  be  employed  after  operation  to  prevent  recurrence, 
and  is  often  of  decided  benefit  in  inoperable  cases. 

Status  lymphaticus,  or  lymphatism,  is  a  hyperplasia  of  the  thy- 
mus, spleen,  lymph  tissues,  and  lymphatic  glands  of  the  entire 
body,  including  the  lymphoid  bone  marrow.  It  may  be  associated 
with  rickets,  goiter,  or  hypoplasia  of  the  heart  and  aorta.  It  may  be 
found  in  adults  but  is  most  frequent  in  children.  This  condition  is 
of  interest  to  the  surgeon,  because  every  now  and  then  it  is  respon- 
sible for  sudden  death  during  or  some  time  subsequent  to  operation, 
often  of  the  most  trivial  nature.  The  cause  of  death  is  not  clear; 
in  a  few  instances  pressure  of  the  enlarged  thymus  on  the  trachea 
seems  to  be  responsible,  but  in  most  cases  a  lympho-  or  thymo-toxemia 
better  fits  the  conditions  found  postmortem.  The  diagnosis  of 
lymphatism  should  make  one  hesitate  to  perform  an  operation  of 
election.  The  patients  are  usually  anemic,  the  tonsils  hypertrophied 
the  lymph  glands  generally  enlarged,  the  thyroid  more  prominent, 
and  the  thymus  increased  in  size  (see  Hyperplasia  of  the  thymus). 


CHAPTER  XVII. 
NERVES 

Neuritis  may  be  acute  or  chronic;  limited  to  a  single  nerve  or 
group  of  nerves,  or  widely  di&tribu.ted{polyneuritis  or  multiple- 
neuritis).  It  is  caused  by  external  influences,  such  as  cold,  injuries 
and  extension  of  inflammation  from  contiguous  structures;  or  by 
toxic  or  infectious  agents  reaching  the  nerves  through  the  blood, 
such  as  lead,  arsenic,  alcohol,  diphtheria,  gout,  rheumatism,  syphilis, 
beri-beri,  etc. 

The  symptoms  of  the  localized  form,  which  alone  is  amenable  to 
surgical  treatment,  are  sharp  pain  and  tenderness  along  the  nerve, 
which  is  sometimes  palpably  swollen.  In  the  early  stages  there  may  be 
hyperesthesia  of  the  skin,  and  twitching  or  spasms  of  the  muscles; 
later  with  the  onset  of  degenerative  changes  there  are  paresthesia, 
such  as  numbness  or  formication,  and  possibly  complete  anesthesia, 
paresis  or  paralysis  of  the  muscles,  and  various  trophic  lesions,  such 
as  edema,  glossy  skin,  loss  of  the  hair  and  nails,  ankylosis  of  joints, 
ulcers,  localized  sweating,  and  atrophy  of  the  muscles  (which  show 
the  reaction  of  degeneration).  Particularly  in  traumatic  cases  the 
inflammation  may  spread  upwards  to  the  spinal  cord,  and  even  to 
the  corresponding  nerve  on  the  opposite  side  of  the  body.  The 
duration  of  neuritis  varies  from  days  to  months  or  years  and  recovery 
may  be  complete  or  only  partial. 

The  treatment  is  removal  of  the  cause  if  possible,  and  during 
the  early  stages,  complete  immobilization,  cold  or  heat,  and  nerve 
sedatives.  Counterirritation  with  a  series  of  blisters  is  often  of 
value.  Any  existing  diathesis  should  be  treated.  In  the  later 
stages  strychnin,  massage,  electricity,  and  active  and  passive  motions 
for  the  prevention  or  alleviation  of  degenerative  changes  are  indi- 
cated. When  internal  medication  fails,  the  nerve  may  be  pierced 
with  needles,  which  are  allowed  to  remain  for  a  short  time  (acupunc- 
ture) ;  injected  with  cocain,  chloroform,  alcohol,  Schleich's  solution,  or 
osmic  acid  (see ' '  Fifth  Nerve  ") ;  cut  {neurotomy) ;  resectedineurectomy) 
or  avulsed  if  the  nerve  itself  is  of  little  importance ;  when  the  nerve  is  an 
important  one,  it  may  be  stretched  (neurectasy) ;  or  the  sheath  opened 
and  the  fibers  separated  by  blunt  dissection;  and  finally,  in  desperate 
cases,  the  sensory  roots  in  the  spinal  canal  or  the  skull  may  be 
divided  or  the  ganglia  excised. 

342 


NERVES  343 

Neuralgia  is  a  paroxysmal  stabbing  or  burning  pain  in  a  nerve  or 
group  of  nerves,  lasting  from  a  few  seconds  to  hours,  and  recurring 
at  widely  varying  intervals.  The  nerve  may  be  tender  at  a  point 
where  it  leaves  a  bony  canal  or  courses  over  a  resistant  structure 
{points  douloureux)  and  pressure  on  these  points  may  precipitate  an 
attack.  The  muscles  may  twitch  or  be  violently  contracted  during 
the  paroxysm,  and  trophic  changes  may  be  found  in  the  area  over 
which  the  nerve  presides.  Causalgia  (W(jir  Mitchell)  is  severe  burn- 
ing pain,  coming  in  paroxysms,  which  may  be  induced  by  a  light 
touch,  cold,  heat,  and  even  emotional  influences.  It  follows  injury 
to  a  nerve,  most  often  the  median,  and  is  generally  due  to  adhesions 
about  the  nerve  or  to  neuritis. 

The  causes  of  neuralgia  are  those  of  neuritis,  or  those  of  reflex 
irritation,  such  as  carious  teeth,  errors  of  refraction,  worms,  and 
diseases  of  the  nose,  throat,  and  ovary.  Anemia,  nervous  tempera- 
ment, and  physical  debility  strongly  predispose  to,  if  not  actually 
cause,  the  disease  in  many  cases.  Neuralgia  is  called  true  when  no 
cause  can  be  found,  secondary,  or  symptomatic,  when  due  to  some 
general  or  local  affection.  The  more  thoroughly  one  studies  the 
disease  the  more  often  will  the  source  of  irritation  be  discovered; 
thus  sicatica  may  be  due  to  a  pelvic  tumor,  intercostal  neuralgia  to 
spondylitis  or  a  tumor  of  the  spinal  cord,  and  neuralgia  of  the  testicle 
to  an  incipient  hernia. 

The  treatment  of  symptomatic  neuralgia  is  that  of  the  cause. 
In  true  neuralgia,  the  general  health  should  be  built  up  by  fresh  air, 
good  food,  and  tonics.  Nerve  sedatives  and  hypnotics  are  used 
during  the  attack,  which  in  some  cases  may  be  terminated  by  pres- 
sure over  the  nerve,  or  by  freezing  with  chlorid  of  ethyl.  Morphin  is 
often  absolutely  necessary,  but  in  chronic  cases,  as  in  neuritis,  should 
be  used  with  caution.  The  surgical  treatment  is  that  of  neuritis. 
For  the  special  forms  of  neuralgia  the  reader  is  referred  to  the  section 
on  "Special  Nerves"  and  the  chapters  on  regional  surgery. 

Tumors  of  nerves  include  the  true  neuromata  (rare) ,  made  up  of 
medullated  {myelinic)  or  non-medullated  {amyelinic)  nerve  libers, 
and  the  false  neuromata,  which  are  usually  fibrous  or  myxomatous 
growths  arising  from  the  peri-  or  endoneurium.  Occasionally 
sarcoma  develops  in  the  same  situation. 

False  neuromata  may  be  single  or  multiple,  and  vary  greatly  in 
size.  A  painful  subcutaneous  tubercle  is  a  small  fibroma  developing 
from  the  sheath  of  a  nerve  filament.  When  involving  a  large  nerve, 
a  false  neuroma  may  be  painless  except  when  pressed  upon.  The 
function  of  the  nerve  is  seldom  disturbed. 


344  MANUAL    OF    SURGERY 

The  treatment  of  neuroma  is  removal.  A  false  neuroma  of  a  large 
nerve  can  usually  be  enucleated  alter  splitting  the  neural  sheath 
longitudinally  and  separating  any  nerve  fibrils  that  may  be  spread 
over  the  growth.  If  removal  cannot  be  effected  without  destroying 
the  continuity  of  the  nerve,  this  should  be  done  and  the  ends  sutured. 
The  treatment  of  traumatic  neuroma,  a  term  often  apphed  to  the 
bulbous  proximal  end  of  a  divided  nerve,  is  excision  (see  "Amputa- 
tions")- 

Neurofibromatosis  {Recklinghausen'' s  disease)  may  be  congenital, 
hereditary,  or  familial,  and  effects  the  male  more  often  than  the 
female.  It  is  of  long  duration,  and  finally  terminates  in  death, 
often  owing  to  the  development  of  sarcoma  or  phthisis.  The  varie- 
ties mentioned  below  may  exist  singly  or  in  combination. 

Multiple  neuro  fibromata  may  be  limited  to  a  single  nerve  trunk,  or 
to  a  nerve  and  its  branches  {plexiform  neuroma),  often  one  of  the 
head  or  the  neck,  in  which  event  the  thickened,  tortuous,  elongated 
filaments  can  be  felt  beneath  the  skin;  or  there  may  be  a  widespread 
thickening  {generalized  neuro  fibromatosis)  of  many,  indeed  all,  of  the 
nerves  of  the  body,  with  the  development  of  multiple  tumors  spring- 
ing from  the  connective  tissue  of  the  nerves.  The  tumors  may  be 
tender  or  there  may  be  no  symptoms.  Paralysis  is  uncommon, 
unless  growths  arise  in  the  spinal  canal. 

Cutaneous  neurofibromata  {molluscum  fihrosuni)  are  soft,  lobulated, 
or  flap-like  tumors  which  vary  greatly  in  size,  and  may  be  scattered 
over  the  entire  body,  except  the  palms  of  the  hands  and  the  soles  of 
the  feet.  They  are  supposed  to  originate  in  the  sheaths  of  the 
dermal  nerves. 

Elephantine  thickening  of  the  entire  cutaneous  and  subcutaneous 
tissue  covering  a  part,  e.g.,  the  leg  {elephantiasis  neuromatosa,  pachy- 
dermatocele),  is  really  a  dift'usion  of  molluscum  fibrosum.  It  differs 
from  other  forms  of  elephantiasis  in  that  it  may  exist  at  birth  {con- 
genital elephantiasis)  and  be  associated  with  multiple  neuromata. 

Brownish  pigmentation  of  the  skin,  in  patches  or  diffused,  may 
appear  in  any  of  the  forms  of  neurofibromatosis,  the  face,  the  neck, 
and  the  trunk  being  the  regions  most  often  discolored. 

The  treatment  of  plexiform  neuroma  is,  in  some  cases,  excision. 
Generalized  neurofibromatosis  is  not  amenable  to  surgical  treatment 
if  one  excepts  amputation  for  an  elephantiasis  neuromatosa  that,  by 
its  size  and  weight,  interferes  with  locomotion. 

Injuries  of  Nerves.- — Concussion  of  a  nerve  may  occur  when  it  is 
violently  jarred,  e.g.,  by  a  bullet  which  passes  close  to  the  nerve. 
In  the  pure  form  there  is  no  anatomical  lesion  and  only  a  temporary. 


NERVES  345 

usually  inc()ni])lete,  suspension  of  the  function  of  the  nerve  (cf. 
"Cerebral  Concussion"). 

Contusion  of  a  nerve  causes  violent  pain,  and  if  severe,  signs  of 
incomplete  or  complete  section  of  the  nerve  (vide  infra).  It  may  be 
followed  by  neuritis  and  subsequent  degeneration.  The  treatment 
is  rest,  and  later  massage  and  electricity.  If  the  symptoms  are  those 
of  complete  section  and  the  reaction  of  degeneration  appears,  the 
nerve  should  be  exposed  by  an  incision,  when  it  may  be  discovered 
that  the  injury  is  a  rupture  instead  of  a  contusion,  in  which  event  the 
nerve  should  be  sutured.  Usually  the  site  of  injury  is  marked  by  a 
thickened,  indurated  area,  which  should  be  resected,  and  the  ends  of 
the  nerve  sutured.  If  no  change  in  the  nerve  can  be  found,  the 
incision  is  closed. 

Compression  of  a  nerve  may  be  caused  by  tumors,  aneurysms, 
fractures,  dislocations,  cicatricial  tissue,  callus  formation,  tourni- 
quets, splints,  crutches,  etc.  Acute  compression,  such  as  that  due  to 
lying  on  the  arm  during  sleep  or  other  unconscious  states,  causes 
anesthesia  and  paralysis,  or  in  the  slighter  forms  a  sensation  of 
numbness  or  tingling.  Chronic  compression,  gradually  produced, 
causes  at  first  increase  in  the  function  of  the  nerve,  i.e.,  neuralgia, 
and  twitching  or  spasms  of  the  muscles,  and  later,  anesthesia,  paraly- 
sis, and  trophic  changes.  The  treatment  is  removal  of  the  cause, 
massage,  and  electricity.  After  the  liberation  of  a  nerve  from  callus 
or  cicatricial  tissue  (neurolysis)  its  sheath,  if  much  thickened,  should 
be  split  longitudinally,  in  order  to  relieve  the  fibers  of  the  pressure 
thus  exerted,  and  the  nerve  may  be  wrapped  in  muscle,  Cargile 
membrane  or,  best,  fat  to  prevent  the  reformation  of  adhesions. 
After  neurolysis  the  function  of  the  nerve  is  restored  in  65  per  cent, 
of  the  cases  (Hashimoto). 

Complete  rupture  or  section  of  a  peripheral  nerve  is  followed 
by  (i)  immediate  paralysis  if  it  contains  motor  fibers;  (2)  imme- 
diate anesthesia  if  it  contains  sensory  fibers;  and  (3)  by  trophic 
changes. 

1 .  Paralysis  involves  all  the  muscles  supplied  exclusively  by  the 
nerve.  It  may  be  recalled  that  certain  muscles  are  supplied  by  more 
than  one  nerve,  and  that  as  most  movements  are  the  result  of  the 
action  of  several  muscles,  it  is  necessary,  in  order  to  determine  the 
exact  extent  of  the  paralysis,  to  investigate  the  muscles  themselves 
rather  than  the  movements  which  they  produce. 

2.  Anesthesia  of  the  skin  is  complete  only  in  the  area  supplied 
exclusively  by  the  nerve;  in  the  parts  which  it  supplies  in  common 
with  other  nerves,  loss  of  sensation  is  incomplete  or  absent.     Sherren 


34^  MANUAL   OF    SURGERY 

divides  the  peripheral  sensory  nerve-fibers  into  three  classes:  (a) 
Nerve- fibers  of  deep  sensation  recognize  deep  pressure  and  the  position 
and  movements  of  the  bones  and  joints.  They  accompany  the  motor 
nerves  to  the  muscles  and  course  through  tendons,  ligaments,  and 
bones,  hence  deep  sensation  is  rarely  impaired,  unless  the  nerve  is 
divided  above  all  its  motor  branches  or  unless  the  muscles  and  ten- 
dons are  severed,  (b)  Protopathic  nerve-fibers  are  important  agents 
in  the  production  of  reflex  movements.  They  appreciate  pain,  e.g., 
a  pin  prick,  and  great  variations  in  temperature,  but  the  sensations 
are  badly  localized,  radiate  widely,  and  are  accompanied  by  tingling, 
As  the  protopathic  fibers  of  adjacent  nerves  overlap  to  a  considerable 
extent,  section  of  a  single  nerve  results  in  a  loss  of  their  functions  in  a 
small  and  variable  area,  (c)  Epicritic  nerve- fibers  perceive  and 
accurately  localize  light  touches,  e.g.,  of  a  hair,  trivial  changes  in 
temperature,  and  the  contact  of  two  points,  e.g.,  of  a  compass,  close 
together.  These  fibers  do  not  overlap  so  much  as  the  protopathic 
fibers,  hence  after  section  of  a  nerve  their  functions  are  destroyed  over 
a  well  defined  and  larger  area,  which  corresponds  in  outline  to  that 
given  in  an  anatomical  treatise  as  representing  the  distribution  of  the 
nerve. 

3.  The  trophic  changes  are  at  first  hyperemia  and  elevation  of  the 
local  temperature,  owing  to  vasomotor  paralysis;  later  the  parts 
become  cold  and  livid.  If  neuritis  is  absent,  the  skin  becomes  dry, 
rough,  scaly,  and  edematous;  if  neuritis  is  present,  thin,  smooth 
shiny,  and  often  bathed  with  sweat.  In  the  latter  instance  vesicular 
and  pustular  eruptions,  painless  ulcers  and  subcuticular  abscesses, 
and  chilblains  may  occur.  The  nails  may  become  curved,  brittle, 
and  ridged  transversely  and  longitudinally,  sometimes  being  shed 
as  the  result  of  paronychia.  The  hair  likewise  becomes  brittle  and 
is  lost.  The  subcutaneous  tissues  and  the  bones  may  atrophy,  and  the 
joints,  especially  those  of  the  fingers,  may  be  the  seat  of  a  plastic 
synovitis  that  eventuates  in  ankylosis.  The  muscles  atrophy  and  are 
ultimately  replaced  by  fibrous  tissue,  deformities  often  resulting  from 
contraction  of  the  unopposed  normal  muscles.  The  electrical  reac- 
tions are  altered.  The  nerve  slowly  fails  to  respond  to  the  faradic 
and  galvanic  currents,  all  excitability  disappearing  after  twelve  days. 
The  muscles  cease  to  react  to  the  faradic  current  in  from  three  to 
eight  days,  but  during  the  first  few  weeks  excitability  by  the  galvanic 
current  is  increased  and  the  reaction  of  degeneration  appears,  i.e.,  the 
anodal  closure  is  greater  than  the  cathodal  closure  contracture,  which 
is  the  reverse  of  normal.  As  the  degenerative  changes  in  the  muscles 
advance,  excitability  by  the  galvanic  current  slowly  diminishes,  until 


NERVES  347 

finally,  after  a  year  or  perhaps  several  years,  all  contractility  is  lost, 
and  recovery  cannot  occur. 

Secondary^  or  Wallerian  degeneration,  takes  place  in  the  proximal 
segment  as  far  as  the  tirst  node  of  Ranvier,  and  in  the  entire  distal 
segment,  the  medullary  substance  undergoing  segmentation,  and 
with  the  axis  cylinders  finally  becoming  absorbed.  These  changes 
are  said  to  occur  whether  the  nerve  is  sutured  at  once  or  not.  If  the 
nerve  does  not  unite,  the  central  end  becomes  bulbous,  owing  to  the 
formation  of  hbrous  tissue  in  which  coils  of  new  axis  cylinders 
appear.  Thus  the  end-bulb  is  really  a  neurofibroma,  and  sometimes, 
particularly  after  amputations,  it  becomes  excessively  painful 
(see  "Amputations'').  The  peripheral  end  also  may  become  bul- 
bous, but  more  commonly  it  shrinks. 

Regeneration  is  thought,  by  some,  to  be  due  to  the  outgrowth  of 
the  undegenerated  axis-cylinders  of  the  prcximal  segment,  which, 
when  the  ends  of  the  nerve  are  approximated  and  occasionally  when 
the  ends  are  separated  some  distance,  force  their  way  downwards 
through  the  distal  segment.  Others  believe  the  axis  cylinders  are 
reformed  by  proliferation  of  the  neurilemma  cells,  and  that  the  distal 
segment  regenerates  even  when  not  brought  in  contact  with  the 
proximal  segment;  certain  it  is  that  sensation  sometimes  returns  so 
rapidly  after  secondary  suture  as  to  be  explainable  only  by  the  union 
of  the  axis- cylinders  from  each  segment.  As  a  rule  regeneration  is 
not  completed  for  many  months  and  sometimes  not  for  several 
years.  In  Gosset's  series  of  cases  of  nerve  suture,  the  first  voluntary 
movements  were  observed  at  periods  ranging  from  three  months 
(median  nerve)  to  21  months  (sciatic  nerve),  the  average 
varying  from  about  six  months  (median  nerve)  to  16  months  (sciatic 
nerve) .  Restoration  of  function  is  first  manifested  by  an  improve- 
ment in  the  nutrition  of  the  part.  Sensation  always  reappears 
before  motion,  which  in  many  cases  is  never  perfectly  regained. 

The  treatment  is  immediate  suture,  or  neurorrhaphy .  The 
principles  of  neurorrhaphy  are  asepsis;  gentleness  (tHe  nerve  should 
not  be  handled  with  forceps) ;  resection,  mth  a  sharp  knife,  of  lac- 
erated ner^^e  ends  or,  in  secondary  neurorrhaphy,  scar  tissue;  ap- 
proximation without  tension  or  axial  rotation,  one  or  two  catgut 
sutures  being  passed  through  the  ends  of  the  nerve,  and  the  sheath 
accurately  stitched  with  the  same  material;  prevention  of  adhesions 
by  covering  the  suture  line  with  fat;  rigorous  hemostasis;  no  drain- 
age. In  secondary  neurorrhaphy  i.e.,  weeks  or  months  after  the 
injury,  the  ner\-e  should  first  be  isolated  above  and  below  the  scar. 
After  the  ends  have  been  found,  they  are  removed  by  shaving  oft" 


348 


MANUAL   OF    SURGERY 


successive  transverse  sections  until  the  nerve  fasciculi  project  as 
isolated  bundles  free  from  fibrous  tissue.  When  the  resulting  gap  is 
wide  it  may  be  closed  by  the  following  methods:  (i)  The  ends  of  the 
nerve  can  be  brought  together  by  stretching  each  segment  and  by 
flexing  the  neighboring  joint,  the  flexion  being  maintained  for  three 
or  four  weeks,  after  which  the  joint  is  gradually  extended ;  by  altering 
the  course  of  the  nerve,  e.g.,  by  transferring  the  ulnar  nerve  to  the 
front  of  the  elbow;  or  by  resecting  bone  in  order  to  shorten  the  limb. 
When  the  ends  of  the  nerve  are  directly  united  more  or  less  function 
returns  in  about  75  per  cent,  of  the  cases.  (2)  Neuroplasty  (Fig. 
142)  is  generally  regarded  as  illogical,  since  the  terminations  of  the 
axis  cylinders,  at  least  in  one  segment,  are  not  brought  in  contact. 
(3)  Anastomosis  with,  or  transplantation  to,  a  neighboring  nerve 
has  given  an  occasional  success  (Figs.  143  to  146).  (4)  Free  trans- 
plantation is  in  the  experimental  stage,  but  a  few  successful  results 


Pig.  142.       Figs.   143,  144,  i45.  146. 

Neuroplasty.  Nerve  transplantation  or  anastomosis; 

paralyzed  nerve  shaded. 


Fig.   147. 
Suture  a  distance. 


have  been  reported.  The  transplant  can  be  obtained  from  the 
paralyzed  nerve,  by  taking  one  half  of  its  thickness  for  an  appro- 
priate distance;  or  a  relatively  unimportant  nerve,  e.g.,  the  radial, 
the  long  saphenous,  or  the  musculocutaneous  of  the  leg,  can  be 
excised,  cut  into  suitable  lengths,  and  the  pieces  tied  together  with 
catgut  so  as  to  form  a  bundle.  Grafts  from  a  recently  amputated 
limb  and  froni  lower  animals  also  have  been  tried.  (5)  Suture  a 
distance  (Fig.  147)  is  useless  unless  the  "distance"  is  very  short. 
(6)  Tubulization  consists  in  placing  each  end  of  the  nerve  in  an  ex- 
cised segment  of  the  vein,  a  segment  of  formalinized  artery,  a  tube 
composed  of  fascia,  decalcified  bone,  or  other  material,  to  prevent 
the  intervention  of  surrounding  structures.  In  nine  cases  of  tubu- 
lization in  animal  experimentation  the  result  was  "good"  in  one, 
"fair"  in  one  (Lewis).  If  the  patient  has  had  an  infected  wound 
neurorrhaphy  should  not  be  performed  until  the  wound  has  been 
healed    for    several  [months,  because   of   the  danger  of  mobilizing 


NERVES  349 

latent  bacteria.  Before  and  after  operation  overstretching  of  par- 
alyzed muscles  should  be  prevented  by  splints  or  braces,  and  mas- 
sage, electricity,  and  passive  motions  used  as  long  as  the  paralysis 
continues.  If  the  operations  listed  above  are  inapplicable  the 
function  of  the  part  may  sometimes  be  improved  by  tenoplasty, 
myoplasty,  or  the  adjustment  of  orthopedic  apparatus. 

Partial  section  of  a  mixed  nerve,  if  not  more  than  one-third  is 
divided,  may  cause  no  symptoms.  Paralysis,  when  present,  is 
incomplete,  and,  although  the  muscles  may  tail  to  respond  to  farad- 
ism,  they  react  promptly  to  the  galvanic  current  and  without  showing 
the  reaction  of  degeneration,  i.e.,  polar  reversal.  Anesthesia  involves 
principally  the  epicritic  nerves,  i.e.,  those  which  appreciate  light 
toucti.  Trophic  disturbances  are  slight  or  absent,  unless  a  neuritis 
is  inaugurated.  Aside  Irom  removal  ot  a  foreign  body,  which  might 
prevent  union  of  the  divided  fibers  or  cause  irritation,  the  treatment 
is  expectant;  and  the  prognosis  is  good.  If  susbequent  to  the  injury 
a  lateral  neuroma  forms  and  causes  trouble  it  m.ay  be  resected  and 
the  divided  fibres  sutured,  after  separating  them,  if  necessary,  from 
the  healthy  portion  of  the  nerve,  in  which  case  the  latter  would, 
at  the  completion  of  the  operation,  be  thrown  into  a  series  of  curves. 

LESIONS  OF  SPECIAL  NERVES 

In  affections  of  the  cranial  neive  trunks  the  loss  of  function  is  on 
the  same  side  as  the  lesion;  if  the  lesion  be  central,  i.e.,  in  the  brain 
the  symptoms  are  referred  to  the  opposite  side  of  the  body. 

The  olfactory  nerve  may  be  injured  in  fractures  of  the  cribriform 
plate  or  in  contusions  of  the  forehead,  resulting  in  transitory  or 
permanent  anosmia  (loss  of  smell). 

The  optic  nerve  also  may  be  involved  in  a  fracture  of  the  base  of 
the  skull,  resulting  in  rupture  or  compression  of  the  nerve.  In  the 
former  event  blindness  is  permanent,  in  the  latter,  particularly  when 
due  to  blood,  vision  may  be  restored.  The  optic  nerve  may  be 
compressed  also  by  inflammations  in  the  orbit,  or  by  tumors,  aneur- 
ysms, foreign  bodies,  or  cicatricial  tissue.  Optic  neuritis  {papil- 
litis, choked  disc)  is  usually  the  result  of  increased  intracranial  pres- 
sure, e.g.  from  tumor  or  abscess  of  the  brain. 

The  third  nerve  (motor  oculi)  may  be  affected  centrally  in  cerebral 
affections,  or  peripherally  by  trauma,  tumors,  etc.  The  nerve 
supplies  the  iris  and  all  the  muscles  of  the  orbit  except  the  superior 
oblique  and  the  external  rectus.  Paralysis  of  the  nerve  causes 
ptosis,  external  squint  with  the  eye  turned  a  little  downwards,  mydria- 


350  MANUAL   OF    SURGERY 

sis,  loss  of  accommodation  owing  to  paralysis  of  the  ciliary  muscle 
and  slight  exophthalmos  owing  to  the  loss  of  tension  exercised  by  the 
muscles. 

The  fourth  nerve  fpatheticus)  supplies  the  superior  oblique, 
paralysis  of  which  causes  impaired  movement  of  the  eye  downwards 
and  outwards. 

The  fifth  or  trigeminal  nerve  supplies  the  face  with  sensation 
and  the  muscles  of  mastication  with  motion.  It  is  rarely  affected 
in  head  injuries,  but  is  often  the  seat  of  neuralgia.  Trifacial  or 
trigeminal  neuralgia,  (called  also  tic  douloureux  in  contradistinction  to 
tic  convulsif,  which  is  a  spasm  of  the  facial  muscles,  and  which  may  or 
may  not  be  associated  with  neuralgia  of  the  fifth  nerve),  usually 
begins  in  the  infraorbital  or  inferior  dental  branches.  It  is  charac- 
terized by  paroxysms  of  excruciating  pain,  often  provoked  by  the 
slightest  irritation,  such  as  a  breath  of  air  or  attempts  at  mastication. 
There  may  be  lacrymation,  an  increase  in  the  amount  of  saliva  and 
nasal  mucus,  unilateral  sweating  of  the  head,  and,  as  already  men- 
tioned, spasm  of  the  facial  muscles.  There  are  two  forms,  the  reflex 
or  symptomatic,  which  may  occur  at  any  time  of  life,  and  true  tic 
douloureux,  which  generally  occurs  after  the  fortieth  year,  and  which 
is  thought  to  be  due  to  a  senile  sclerosis  of  the  nerve  or  the  blood 
vessels.  The  treatment  is  the  removal  of  any  reflex  irritation,  such 
as  errors  of  refraction,  diseases  of  the  nose,  teeth,  ear,  etc.,  and  the 
comibating  of  any  existing  constitutional  affection,  such  as  malaria, 
anemia,  syphilis,  gout,  rheumatism,  or  other  toxic  or  infectious 
condition.  Of  the  many  local  measures  which  have  been  used  may 
be  mentioned  cold,  heat,  menthol,  belladonna,  chloral  croton,  blisters, 
the  cautery,  freezing  of  tender  points  {points  douloureux) ,  and  the 
galvanic  current.  Nerve  sedatives  and  hypnotics  must  be  used  for 
the  pain.  Strychnin  in  increasing  doses,  until  some  physiological 
results  have  been  obtained,  has  been  highly  recommended.  When 
these  measures  fail  operative  treatment  will  be  demanded.  Facial 
neuralgia  has  been  treated  by  ligation  of  the  common  carotid,  resec- 
tion of  the  superior  cervical  ganglion  of  the  sympathetic,  and  by 
stretching  the  seventh  nerve  when  associated  with  tic  convulsif,  but 
practically  all  surgeons  prefer  to  attack  the  fifth  nerve  itself.  Simple 
division  of  the  nerve  and  nerve  stretching  are  very  transient  in  their 
effects  and  are  not  recommended.  In  order  to  effect  a  physiological 
section,  5  or  lom.  of  a  1.5  per  cent,  solution  of  osmic  acid  are  in- 
jected into  the  branches  of  the  nerve  after  they  have  been  exposed  by 
incision.  Alcohol  (80  per  cent.),  formalin,  and  other  substances 
have  been  used  in  a  similar  way,  or  injected  subcutaneously  into 


NERVES  351 

the  nerves  at  their  points  of  exit  from  the  cranium.  The  last  named 
procedure  requires  special  skill  and  is  not  without  danger.  The 
relief  obtained  may  last  from  a  few  weeks  to  a  few  months,  occasion- 
ally a  few  years,  and  rarely  it  may  be  permanent.  More  satisfactory 
from  a  surgical  standpoint  is  resection  of  the  peripheral  branches  of 
the  nerve,  which  may  have  to  be  repeated,  owing  to  the  regeneration 
of  these  filaments.  Regeneration  is  especially  likely  to  occur  when 
the  nerve  occupies  a  bony  canal,  hence,  after  resection,  some  surg- 
eons plug  the  canal  with  gold  foil,  dental  paste,  or  a  similar  material. 
Kanavel  suggests  covering  the  foramen  with  a  flap  of  periosteum, 
or  lining  the  canal  with  an  osseous  transplant.  When  the  entire 
nerve  is  involved  or  recurrences  are  frequent,  more  formidable 
operations  are  required,  even  to  resection  of  the  Gasserian  ganglion. 

Resection  of  the  supraorbital  nerve  may  be  performed  through  an 
incision  about  one  inch  long  in  the  line  of  the  eyebrow,  after  this  has 
been  removed  by  shaving.  The  nerve  makes  its  exit  through  the 
supraorbital  notch  or  foramen,  at  the  junction  of  the  inner  and  middle 
thirds  of  the  upper  margin  of  the  orbit.  As  much  of  each  end  as 
possible  is  removed. 

The  supratrochlear  nerve  may  be  found  at  a  point  where  a  line 
drawn  from  the  angle  of  the  mouth  to  the  inner  canthus  touches 
the  upper  margin  of  the  orbit. 

The  infraorbital  nerve  emerges  from  the  infraorbital  foramen 
about  one-third  inch  below  the  middle  of  the  lower  margin  of  the 
orbit.  A  curved  incision  is  made  below  the  lower  margin  of  the 
orbit  and  the  nerve  isolated.  The  periosteum  of  the  orbital  floor 
is  then  elevated,  the  roof  of  the  infraorbital  canal  opened,  and  the 
nerve  divided  as  far  back  as  possible  and  drawn  out  through  the 
foramen.  By  this  method  even  the  main  trunk  of  the  superior 
maxillary  may  be  reached  and  divided. 

The  superior  maxillary  nerve  and  Meckel's  gangUon  may  be 
removed  by  the  Carnochan-Chavasse  operation.  A  T-shaped  inci- 
sion is  made,  the  horizontal  portion  of  which  runs  from  canthus  to 
canthus  beneath  the  lower  margin  of  the  orbit,  and  the  vertical, 
downwards  from  the  center  of  this  incision  to,  but  not  into,  the  mouth. 
The  infraorbital  nerve  is  isolated  and  secured  with  a  piece  of  silk, 
and  both  the  anterior  and  posterior  walls  of  the  antrum  are  opened 
by  a  gouge  or  chisel,  care  being  taken  not  to  injure  the  internal 
maxillary  artery.  The  infraorbital  canal  is  opened  on  the  roof  of 
the  antrum,  and  the  nerve  divided  on  the  cheek  and  pulled  down 
through  the  antrum.  It  is  then  traced  backwards  to  the  foramen 
rotundum,    where   after   shght   traction   it    is   divided.     Meckel's 


352  MANUAL    OF    SURGERY 

ganglion  is  brought  away  with  the  nerve.  The  same  procedure  has 
been  carried  out  through  the  orbit,  and  from  the  side  of  the  face 
after  resection  of  the  zygoma  and  coronoid  process  of  the  lower  jaw. 

The  inferior  dental  nerve  may  be  resected  by  making  an  incision 
along  the  lower  border  of  the  jaw  back  to  the  angle.  The  masseter 
is  scraped  from  the  bone,  which  is  then  chiseled  or  trephined  about 
one  and  one-fourth  inches  above  the  angle,  so  as  to  remove  the  outer 
half  of  the  thickness  of  the  bone  and  expose  the  nerve  at  its  entrance 
into  the  inferior  dental  foramen.  The  nerve  is  lifted  from  its  bed 
by  a  sharply  curved  hook,  and  as  much  of  each  end  as  possible  re- 
moved by  avulsion.  The  inferior  dental  may  be  resected  also  through 
the  mouth.  A  gag  is  placed  between  the  teeth  of  the  opposite  side, 
and  an  incision  made  along  the  anterior  border  of  the  ramus  of  the 
lower  jaw  to  the  last  molar  tooth.  After  separating  the  internal 
pterygoid  muscle  from  the  bone  and  locating  the  spine  of  Spix,  at  the 
base  of  which  is  the  inferior  dental  foramen,  a  hook  is  passed  around 
the  nerve  and  as  much  of  it  as  possible  removed. 

The  lingual  nerve  may  be  exposed  in  the  mouth  by  making  an 
incision  midway  between  the  tongue  and  the  gum  of  the  last  molar 
tooth,  or  externally  by  an  incision  in  the  submaxillary  triangle. 

The  auriculo -temporal  nerve  may  be  exposed  at  the  root  of  the 
zygoma  by  a  vertical  incision  between  the  temporal  artery  and  the 
pinna. 

The  buccal  nerve  may  be  exposed  by  a  vertical  incision  through  the 
mucous  membrane  and  buccinator  fibers,  the  center  of  the  incision 
being  at  the  middle  of  the  anterior  border  of  the  vertical  ramus  of  the 
inferior  maxilla. 

The  inferior  maxillary  nerve  may  be  divided  at  the  foramen  ovale 
after  resection  of  the  zygoma  or  coronoid  process,  or  both.  Another 
method  is  to  deepen  the  sigmoid  notch  of  the  lower  jaw  three-fourths 
of  an  inch  or  more. 

M5^ter's  operation  is  a  resection  of  the  second  and  third  divisions 
of  the  fifth  nerve  at  their  exit  from  the  skull,  after  temporary  resec- 
tion of  the  zygoma.  In  Abbe's  operation  the  external  carotid  is 
ligated  and  a  vertical  incision  made  above  the  middle  of  the  zygoma. 
The  skull  is  then  opened  by  gouge  and  rongeur,  and  the  second  and 
third  divisions  exposed  extradurally  and  severed  at  the  foramen 
rotundum  and  foramen  ovale.  A  slip  of  gutta-percha  tissue  is 
placed  over  the  foramina  in  order  to  prevent  the  junction  of  the 
divided  nerves. 

Removal  of  the  Gasserian  ganglion  is  indicated  in  cases  in  which 
the  entire  nerve  is  involved,  or  in  which  less  dangerous  operations 


NERVES  353 

have  failed.  In  the  llartlcy-Krause  methods  horseshoe-shaped  osteo- 
plastic flap  consisting  of  scalp  and  bone  is  made  in  the  temporal 
rei!;ion  with  the  base  at  the  zygoma.  In  raising  this  flap  the  middle 
meningeal  artery  is  often  injured.  The  dura  mater  is  not  opened, 
but  is  stripped  from  the  middle  fossa  of  the  skull  until  the  second  and 
third  divisions  of  the  nerve  are  found;  these  are  traced  backward  to 
the  ganglion  at  the  apex  of  the  petrous  portion  of  the  temporal  bone. 
The  dura  I  envelope  (cavum  of  Meckel)  of  the  ganglion  is  then  opened, 
the  ganglion  separated  from  this  envelope,  the  second  and  third 
divisions  divided  near  their  foramina,  and  the  ganglion  twisted  out 
with  forceps.  Cushing,  after  cutting  through  the  zygoma  at  each 
end,  opens  the  skull  lower  down,  so  as  to  avoid  injury  to  the  middle 
meningeal  artery.  Rose  reaches  the  ganglion  through  the  pterygoid 
region  after  resecting  the  zygoma  and  the  coronoid  process  of  the 
lower  jaw.  In  Horsley's  method  the  dura  is  opened  and  the  ganglion 
removed.  In  the  Spiller-Frazier  operation  the  sensory  root  of  the 
ganglion  alone  is  divided.  The  mortality  of  these  operations  is  from 
lo  to  20  per  cent.,  but  the  chance  of  permanent  cure  in  those  who 
survive  is  very  great.  Ulceration  of  the  cornea  may  occur,  and 
should  be  anticipated  by  suturing  the  eyelids  together  at  the  time 
of  operation,  and  later,  if  there  is  the  slightest  irritation,  by  the  wear- 
ing of  a  watch  glass  over  the  eye.  The  cavernous  sinus  and  the 
sixth  nerve  have  both  been  injured  during  operation. 

Division  of  the  sixth  nerve  causes  internal  squint  as  the  result  of 
paralysis  of  the  external  rectus. 

The  seventh  or  facial  nerve  may  be  paralyzed  (Bell's  palsy)  within 
the  cranium  from  tumor,  abscess,  hemorrhage,  thrombosis,  embolism, 
softening  of  the  brain,  etc.;  in  its  passage  through  the  Fallopian  canal 
from  fracture  of  the  base  of  the  skull  and  middle  ear  disease, 
causing  compression  or  neuritis;  and  at  its  emergence  from  the  styloid 
foramen  by  trauma,  tumors,  and  neuritis  from  cold.  When  the 
nerve  is  affected  in  the  cortex,  corona  radiata,  or  internal  capsule, 
the  lower  half  of  the  opposite  side  of  the  face  is  paralyzed,  usually 
with  hemiplegia,  and  the  reactions  of  degeneration  are  absent.  When 
the  lesion  is  in  the  lower  part  of  the  pons,  the  face  is  paralyzed  on  the 
same  side,  and  the  arm  and  leg  on  the  opposite  side  {crossed  paralysis), 
owing  to  the  fact  that  the  motor  fibers  to  the  arm  and  leg  decussate 
in  the  medulla.  A  lesion  between  the  brain  and  the  Fallopian  canal 
is  often  accompanied  by  deafness,  and  the  paralysis  involves  the 
entire  face  of  the  same  side.  Section  of  the  facial  nerve,  where  it  is 
accompanied  by  the  chorda  tympani,  i.e.,  between  the  geniculate 
ganglion  and  the  lower  part  of  the  Fallopian  canal,  causes  loss  of 

23 


354  MANUAL    OF    SURGERY 

taste  over  the  anterior  two-thirds  of  the  corresponding  half  of  the 
tongue. 

The  treatment  is  removal  of  the  cause,  whenever  possible.  Mas- 
sage, electricity,  and  iodid  of  potassium  are  used  in  cases  not  suitable 
for  surgical  treatment.  In  cases  of  extracerebral  origin  in  which 
electrical  examination  reveals  the  presence  of  fairly  healthy  muscles, 
the  nerve  may  be  severed  at  the  stylomastoid  foramen  and  the  distal 
end  sutured  into  the  spinal  accessory  or  hypoglossal  nerve.  The 
extent  of  recovery  is  limited  to  associated  movements  in  conjunction 
with  the  shoulder.  The  cases  most  suitable  for  operation  are  those 
in  which  the  palsy  has  lasted  for  six  months  without  any  signs  of 
recovery.  The  operation  may  be  done  also  in  severe  cases  of  facial 
tic  (clonic  spasms  of  the  facial  muscles)  which  have  resisted  medical 
treatment  and  neurectasy  (Ballance  and  Stewart). 

The  eighth  or  auditory  nerve  may  be  involved  in  tumors,  menin- 
gitis, hemorrhage,  or  traumatism,  often  resulting  in  incurable  deafness. 
It  has  been  divided  for  uncontrollable  tinnitus  of  peripheral  origin. 

Lesions  of  the  glossopharyngeal  nerve  are  rare;  paralysis  would 
affect  taste,  swallowing,  and  possibly  speaking. 

The  tenth  or  pneumogastric  nerve  may  be  compressed  by  tumors 
or  aneurysms,  or  injured  in  fracture  of  the  base  of  the  skull  or  in 
operations  on  the  neck.  Irritation  may  cause  vomiting,  inhibition 
of  the  heart,  and  spasm  of  the  laryngeal  muscles.  Division  of  one 
pneumogastric  may  be  followed  by  few  or  no  symptoms,  but  division 
of  both  nerves  causes  death  from  paralysis  of  the  laryngeal  muscles. 
A  lesion  of  the  pneumogastric  nerve  in  the  lower  part  of  the  neck,  or 
of  the  recurrent  laryngeal  branch,  causes  paralysis  of  the  muscles  of 
one  side  of  the  larynx,  with  resulting  hoarseness  and  impaired 
phonation. 

The  eleventh  or  spinal  accessory  nerve  is  exposed  to  wounds  and 
many  forms  of  irritation.  Section  of  the  branch  which  joins  the 
pneumogastric  results  in  paralysis  of  the  laryngeal  muscles.  The 
external  branch  is  distributed  to  the  sternomastoid  and  trapezius, 
which  muscles  may  not  be  completely  paralyzed  after  division  of  the 
nerve,  as  they  receive  filaments  also  from  the  cervical  nerves.  The 
nerve  has  been  stretched  or  divided  for  spasmodic  torticollis. 

The  twelfth  or  hypoglossal  nerve  when  divided,  causes  paralysis 
of  one  side  of  the  tongue,  which,  when  protruded,  is  directed  to  the 
paralyzed  side;  deglutition  also  may  be  impaired. 

The  phrenic  nerve,  when  irritated,  causes  hiccough,  and  when 
divided,  paralysis  of  the  diaphragm,  which,  if  unilateral,  is  often 
scarcely  noticeable,  but  if  bilateral  may  cause  instant  death. 


NERVES  355 

The  brachial  plexus  miiy  be  injured  (a)  above  or  (b)  below  the 
clavicle. 

(a)  Supraclavicular  injuries  may  be  direct,  e.g.,  from  penetrating 
wounds,  fracture  of  the  clavicle  or  cervical  spine,  or  pressure  of  a 
cervical  rib;  or  indirect,  the  nerves  being  overstretched  or  ruptured 
as  the  result  of  traction,  the  direction  and  violence  of  the  force 
determining  the  grade  and  extent  of  the  paralysis,  of  which  there 
are  three  common  types. 

1.  The  upper  arm,  or  Duchenne-Erh  type,  is  the  most  frequent. 
It  is  due,  not  to  the  pressure  of  the  clavicle,  as  has  been  thought, 
but  to  a  forcing  apart  of  the  head  and  shoulder,  the  brunt  of  the 
strain  falling  upon  the  anterior  primary  division  of  the  fifth  cervical 
nerve,  hence  paralysis  of  the  deltoid,  supraspinatus,  infraspinatus, 
biceps,  brachiahs  anticus,  supinator  longus,  and  supinator  brevis, 
which  causes  loss  of  abduction  and  outward  rotation  of  the  arm  and 
loss  of  flexion  and  supination  of  the  forearm.  Sensation  is  not  im- 
paired. When  the  traction  is  less  severe  only  the  upper  part  of  the 
fifth  cervical  may  be  ruptured,  resulting  in  paralysis  of  the  deltoid 
and  spinati;  as  these  cases  follow  a  blow  on  the  shoulder  they  are 
frequently  diagnosticated  as  injury  to  the  circumflex  nerve  (Sherren). 

2.  The  lower  arm,  or  Klumpke  type,  is  caused  by  upward  traction 
on  the  arm.  e.g.,  when  a  man  saves  himself  from  a  fall  from  a  height 
by  clutching  a  projection  of  some  sort.  In  these  cases  the  first  dorsal 
nerve  is  stretched  or  torn,  and  the  intrinsic  muscles  of  the  hand  and 
often  the  cervical  sympathetic  nerve  are  paralyzed.  Anesthesia 
exists  over  the  inner  side  of  the  arm  and  forearm,  and  occasionally 
along  the  ulnar  border  of  the  hand. 

3.  The  whole  plexus  type  may  be  due  to  upward  or  downward 
traction,  when  of  severe  grade.  All  the  muscles  of  the  upper  ex- 
tremity, excluding  the  rhomboids  and  the  serratus  magnus,  are 
paralyzed,  usually  with  impairment  of  the  functions  of  the  cervical 
sympathetic  nerve.  Anesthesia  exists  over  the  whole  limb,  except- 
ing the  area  along  the  inner  side  of  the  arm  suppHed  by  the  intercosto- 
humeral  nerve. 

(b)  Infraclavicular  injuries,  aside  from  penetrating  wounds,  are 
usually  the  result  of  direct  pressure,  e.g.,  from  a  crutch,  from  disloca- 
tion or  fracture  of  the  upper  end  of  the  humerus  or  attempts  to  reduce 
the  deformity  in  these  cases,  especially  by  the  heel-in-axilla  method. 
The  two  common  forms  are  the  whole  plexus  type,  which  differs 
from  that  of  the  supraclavicular  variety,  in  that  the  anesthesia  is 
complete,  and  the  inner  cord  type,  which  gives  the  symptoms  of 
injury  to  the  ulnar  nerve,  with  paralysis  of  the  muscles  of  the  hand 


356  MANUAL    OF    SURGERY 

supplied  by  the  median  nerve.  Lesions  of  the  outer  cord  are  accom- 
panied by  paralysis  of  the  biceps,  coracobrachialis,  and  the  muscles 
innervated  by  the  median,  except  those  of  the  hand,  and  by  anesthe- 
sia of  the  outer  side  of  the  forearm.  Lesions  of  the  posterior  cord 
cause  symptoms  identical  with  those  of  the  musculospiral  and  circum- 
flex nerves. 

Post-anesthetic  paralysis  of  the  brachial  plexus  is  usually  of  the 
Duchenne-Erb  type,  the  causative  traction  being  exerted  by  the 
abducted  arm  hanging  from  the  edge  of  the  table.  Those  cases 
following  elevation  of  the  arm  above  the  patient's  head  are  due  to 
pressure  of  the  upper  end  of  the  humerus,  and  are  of  the  infraclavicu- 
lar variety. 

Brachial  birth  paralysis  usually  involves  the  left  arm  and  is  usually 
due  to  forcible  separation  of  the  head  from  the  shoulder,  hence  of 
the  Duchenne-Erb  type,  although  the  lower  arm  type  may  follow  a 
breech  presentation  with  the  arms  extended,  and  in  severe  cases 
the  whole  plexus  may  be  involved. 

The  treatment  of  brachial  paralysis  depending  upon  direct 
wounds,  or  pressure  from  callus,  displaced  bone,  etc.,  is  that  of  the 
same  injuries  afTecting  other  nerves.  Spontaneous  recovery  is  the 
rule  in  post-anesthetic  paralysis,  crutch  palsy,  and  lesions  of  similar 
intensity.  Birth  paralysis  ultimately  disappears  in  perhaps  three- 
fourths  of  the  cases,  but  in  adults  not  more  than  40  per  cent,  of  the 
traction  paralyses  due  to  great  violence  recover  without  operation. 
In  all  cases,  as  soon  as  the  tenderness  due  to  the  accident  has  sub- 
sided, massage,  electricity,  and  passive  motions  should  be  ordered. 
If,  in  the  course  of  several  months,  improvement  does  not  follow 
this  form  of  treatment,  and  especially  if  the  muscles  show  the  reaction 
of  degeneration,  operation  should  be  advised.  Kennedy,  however, 
counsels  delay  in  birth  palsy  for  at  least  one  year.  An  incision  is 
made  from  the  junction  of  the  upper  and  middle  thirds  of  the  posterior 
border  of  the  sternomastoid  to  the  junction  of  the  middle  and  outer 
thirds  of  the  clavicle,  and,  if  the  lower  branches  of  the  plexus  must 
be  exposed,  the  clavicle  divided  temporarily.  After  severing  the 
deep  fascia  an  attempt  is  made  to  identify  the  individual  parts  of 
the  plexus,  often  a  most  difficult  undertaking,  owing  to  the  mass  of 
cicatricial  tissue  in  which  they  are  imbedded.  If  the  nerves  have 
been  divided  they  are  sutured;  if  destroyed  by  scar  tissue,  resected 
and  then  united.  If  so  much  of  a  nerve  must  be  excised  that  its 
ends  cannot  be  brought  together,  the  distal  segment  is  anastomosed 
with  a  neighboring  nerve.  If  operation  on  the  nerves  fails,  muscular 
transplantation  may  be  tried.     In  Duchenne-Erb  paralysis  Tubby 


NERVES  ,^57 

has  restored  llexion  of  the  forearm  by  transj)hinting  a  portion  of  the 
triceps  to  the  biceps,  and  alxluction  of  the  arm  by  transplanting  a 
portion  of  the  i)ectoraHs  major  and  tra])ezius  to  the  deltoid. 

Xeurilis  of  any  of  the  nerves  of  the  arm  may  spread  to  and 
involve  the  entire  brachial  plexus,  and  the  plexus  is  occasionally 
the  seat  of  intractable  neuralgia,  for  which  it  has  been  exposed  and 
stretched. 

The  posterior  thoracic  nerve  may  be  injured  or  inflamed,  causing 
paralysis  of  the  serratus  magnus,  or  winged  scapula  (q.v.). 

The  circumflex  nerve  winds  around  the  neck  of  the  humerus 
three-fourths  of  an  inch  above  the  middle  of  the  deltoid.  It  is  often 
involved  in  injuries  about  the  shoulder,  resulting  in  paralysis  of  the 
deltoid  and  teres  minor,  and  transient  anesthesia  of  the  posterior 
fold  of  the  axilla. 

The  musculospiral  nerve  is  the  largest  nerve  in  the  arm  and  the 
most  abused  nerve  in  the  body.  It  is  often  injured  by  gunshot  and 
stab  wounds,  and,  especially  where  it  lies  close  to  the  bone  in  the 
musculospiral  groove,  by  fractures  of  the  humerus.  It  is  frequently 
compressed  also  in  crutch  palsy,  by  lying  on  the  arm,  and  by  a 
tourniquet,  and  is  pecuHarly  prone  to  be  affected  by  lead  poisoning. 
Division  of  the  nerve  near  the  plexus  causes  paralysis  of  the  extensor 
muscles  of  the  elbow,  wrist  (wrist-drop),  fingers,  and  thumb,  and, 
excepting  the  biceps,  of  the  supinators  of  the  forearm  (Fig.  148). 
Extension  of  the  terminal  phalanges  may  still  be  accomplished  by  the 
interossei  and  lumbricales.  Sensation  is  lost  over  the  anterior 
and  posterior  aspects  of  the  radial  side  of  the  elbow  and  forearm,  the 
radial  side  of  the  posterior  surface  of  the  wrist  and  hand,  and  over  the 
dorsal  surface  of  the  thumb,  first,  second,  and  half  the  third  fingers 
(Fig.  151).  In  lead  palsy  both  arms  are  usually  involved,  but  the 
supinator  longus  and  the  triceps  often  are  unaffected.  In  cases  of 
pressure  palsy  massage  and  electricity  will  be  required,  recovery 
usually  ensuing  in  a  variable  length  of  time.  When  the  nerve  is 
caught  in  callus  or  divided,  operation  will  be  necessary.  So  long  as 
the  paralysis  continues  the  wrist  and  the  proximal  phalanges  of  the 
fingers  should  be  kept  extended  by  means  of  a  splint  or  by  orthopedic 
apparatus.  When  the  nerve  cannot  be  repaired  the  treatment  just 
mentioned  may  be  employed,  or  the  tendon  of  the  flexor  carpi 
radialis  implanted  in  the  extensor  tendons  of  the  fingers  (Murphy). 

The  median  nerve,  when  divided  above  the  bend  of  the  elbow, 
causes  paralysis  of  the  pronators,  flexor  carpi  radialis,  palmaris 
longus,  flexor  longus  pollicis,  flexor  sublimis,  and  the  radial  half  of 
the  flexor  profundus  digitorum,  with  the  following,  which  alone  are 


358 


MANUAL    OF   SURGERY 


involved  in  an  injury  just  above  the  wrist,  abductor,  opponens,  and 
outer  half  of  the  flexor  brevis  pollicis,  and  the  two  radial  lumbricales. 
There  is  loss  of  sensation  in  the  skin  of  the  radial  side  of  the  hand, 
the  flexor  surface  of  the  thumb,  and  in  the  first,  second,  and  half  the 
third  fingers,  which  are  involved  to  a  varying  degree  also  on  the 
dorsal  surface  (Fig.  151).  There  are  loss  of  pronation,  impaired 
radial  flexion  and  abduction  of  the  wrist,  loss  of  the  hand  grasp  on  the 


Pig.  148. — Wrist-drop  after  section  of     Fig.   149. — Hand  after  section 
musculospiral  nerve.      (Gowers.)  of  median  nerve.      (Dagron.) 


radial  side,  and  wasting  of  the  thenar  eminence  (Fig.  149).  Flexion 
of  the  proximal  phalanges  by  means  of  the  interossei  is  still  possible. 
The  ulnar  nerve  suppHes  the  flexor  carpi  ulnaris,  the  ulnar  half 
of  the  flexor  profundus,  the  two  ulnar  lumbricales,  all  the  interossei, 
the  muscles  of  the  little  finger,  the  adductors  of  thumb,  the  ulnar 
half  of  the  flexor  brevis  pollicis,  and  the  skin  of  the  anterior  and 
posterior  surfaces  of  the  ulnar  side  of  the  hand,  including  the  little 

finger  and  the  ulnar  half  of  the  ring 
finger.  After  division  of  this  nerve 
there  are  anesthesia  in  the  area  just 
mentioned  (Fig.  151),  impairment  of 
ulnar  flexion  and  adduction  of  the 
wrist,  weakened  hand  grasp  in  the 
ring  and  little  fingers,  loss  of  adduc- 
tion and  abduction  of  the  fingers,  and 
extension  of  the  proximal  phalanges 
and  flexion  of  the  second  and  third 
phalanges  of  all  the  fingers  (claw  hand),  with  atrophy  of  the  interossei, 
causing  marked  prominence  of  the  interosseous  spaces  (Fig.  150). 
Dislocation  of  the  ulnar  nerve  in  front  of  the  inner  condyle  may  occur; 
it  has  been  treated  by  suturing  a  flap  of  fibrous  tissue  over  the 
nerve  to  the  triceps  tendon,  after  reduction  has  been  eft'ected. 

A  simple  test  for  determining  the  integrity  of  the  nerves  supply- 


FlG. 


150. — Hand    after    section    of 
ulnar  nerve.     (Gowers.) 


NERVES 


359 


ing  the  hand  is  as  follows:  If  the  wrist  can  be  extended  the  musculo- 
spiral  is  intact;  if  the  index  finger  can  be  flexed  while  the  wrist  is 
flexed  and  pronated  (position  of  wrist  drop)  the  median  is  intact; 
if  the  little  finger  can  be  abducted  and  adducted  the  ulnar  is  intact. 
The  lumbar  plexus  may  be  affected  by  injuries,  by  tumors,  and 
by  disease  of  the  vertebra?.     It  supplies  sensation  to  the  lower  part  of 


Itl  DIVISION  OF 5(h 

Sd  DIVISJOS  OF  Slh  . 
W  Dl  VISIOS  OF  Slh 
GKFA  T  A  VRICULA  R 

t,  3  C,  SUPERFICIAL  CERVICAL 


CIRCVMFLEX 
LA  TERA  L  CUT  A  SEOVS 
SERVES 
ASTERIOR    CUTANE- 
OUS SERVES 

IBSSBR  rSTBR.VAL  CCTAyg- 
orS  ASO    IS7ERCOSrO-HU- 

MBRAL.  I.  s  D 

VPPER   EI7SRSAL    CPTANB- 

urs  OF  MVSCVL0-3PIRAL 

ISTERSAL  CUTANEOUS 


SUPRAORBITAL 

Or.EAT  OCCIPITAL 
iMALL  OCCIPITAL 
S.VA  I.LEST  OCCIPITAL 
(iREAT  AURICULAR 


SUPERFICIAL  DE- 
SCESUISG   CERVI- 
CAL,!, kC 

CIRCUMFLEX,  5,6  C 


lATSRCOSTO-Bl'MSRAL 

LESSSR  1ST.   Ci'TASEOt  y 
ISTERSAL  CITASEOVS  OF 


KUSCULO-CUTANEOUS   - 


GESITO-CRURAL 


RADIAL.  6  C 
nio-isaviSAj..t  l—- 

HE  V  IAS.  t,  7.9  C.I  D 

ULSAR,  1  D 


SlFPl.IED   BT 


ISTERSAL  gUTANBOUS    — 
MIDDLE  CUTANEOUS  ■  - 


EXTERNAL  POPLITEAL 
INTERNAL  SAPHENOUS   •-• 


MUSCULO-CVTANEOVS 

E-^TERNAL  SAPHENOUS   - 

ANTERIOR  TIBIAL     - 
ISTERSAL  PLaSTAP. 


EXTERNAL  POPLITEAL.S  L.l.iS 
INTERNAL  SAPHESOrs.  S.l  L 

■  EXTERNAL  SAPIIESOVS,  l.tS 


EXTERNAL  PLANTAR,  1, 
INTERNAL  PLANTAR.  '.,  S  L.l  S 


Pig.    151. — Diagram  showing  the  areas  of  distribution  of  cutaneous  nerves.      (Morris.) 


the  abdomen,  the  anterior  and  lateral  aspects  of  the  thigh,  and  to  a 
portion  of  the  inner  side  of  the  leg  and  foot.  It  supphes  also  the 
flexors  and  the  adductors  of  the  hip,  the  extensors  of  the  leg,  and  the 
cremaster. 

The  obturator  nerve  may  be  injured  during  parturition,  resulting 


360  MANUAL   OF    SURGERY 

in  paralysis  of  the  adductors  of  the  thigh,  the  patient  being  unable  to 
cross  the  legs.     External  rotation  also  is  impaired. 

The  anterior  crural  nerve,  when  divided,  results  in  paralysis  of  the 
extensors  of  the  knee,  and  anesthesia  over  the  front  and  sides  of  the 
thigh,  and  the  inner  side  of  the  leg,  foot,  and  big  toe  (Fig.   151). 

The  sacral  plexus  innervates  the  rotators  and  extensors  of  the  hip, 
the  flexors  of  the  knee,  all  the  muscles  of  the  foot,  and  the  skin  of  the 
buttock,  posterior  surface  of  the  thigh,  outer  and  posterior  portion  of 
the  lower  leg,  and  almost  the  entire  foot.  It  may  be  compressed  by 
pelvic  tumors  or  inflammations,  injured  during  child  birth,  or 
involved  in  a  neuritis,  which  is  often  an  extension  from  the  sciatic 
nerve. 

The  superior  gluteal  nerve  supplies  the  gluteus  medius  and  mini- 
mus, hence  its  division  results  in  loss  of  abduction  and  circumduc- 
tion of  the  thigh. 

The  small  sciatic  nerve  is  not  often  injured.  Its  division  results 
in  paralysis  of  the  gluteus  maximus,  and  anesthesia  of  the  posterior 
surface  of  the  middle  third  of  the  thigh,  and  of  the  upper  half  of  the 
calf  of  the  leg. 

The  great  sciatic  nerve,  when  severed  near  the  sciatic  notch,  causes 
paralysis  of  the  flexors  of  the  leg  (which  are  also  extensors  of  the  hip), 
and  of  all  the  muscles  below  the  knee  joint;  the  latter  muscles  alone 
are  involved  when  the  injury  is  below  the  middle  of  the  thigh. 
Anesthesia  exists  in  the  outer  half  of  the  leg,  and  in  the  sole  and  the 
greater  part  of  the  dorsum  of  the  foot.  This  nerve  is  frequently 
affected  by  a  very  painful  form  of  neuralgia  (,?«cz//'cfl),  in  intractable 
cases  of  which  neurectasy  may  be  required.  This  has  been  accom- 
plished by  flexing  the  extended  lower  extremity  upon  the  abdomen, 
under  an  anesthetic.  In  the  open  operation  the  nerve  is  exposed 
midway  between  the  great  trochanter  and  the  tuber  ischii,  by  an 
incision  three  or  four  inches  long,  made  in  the  middle  of  the  thigh 
from  the  gluteal  fold  downwards.  The  lower  border  of  the  gluteus 
maximus  is  exposed,  the  ham-string  muscles  retracted  inwards,  and 
the  nerve  hooked  up  by  the  finger  and  stretched  both  centrally  and 
peripherally,  enough  force  being  used  to  lift  the  lower  extremity  from 
the  table. 

The  external  popliteal  nerve  may  be  severed  in  cutting  the  tendon 
of  the  biceps  subcutaneously,  or  compressed  against  the  neck  of  the 
fibula  by  bandages  or  splints.  Section  of  this  nerve  causes  paralysis 
of  the  peroneal  group  of  muscles,  the  tibialis  anticus,  the  extensor 
longus  hallucis,  and  the  extensor  longus  and  brevis  digitorum,  with 
anesthesia  of  the  outer  half  of  the  anterior  surface  of  the  leg  and  the 


NERVES  361 

dorsum  of  the  fool.  The  ankle  cannot  be  flexed  on  the  leg  {jool- 
drop),  and  in  old  cases  talipes  equinus  develops. 

The  internal  popliteal  nerve,  when  divided,  causes  paralysis  of  the 
muscles  of  the  calf,  extensors  of  the  foot,  flexors  of  the  toes,  and  of  the 
muscles  of  the  sole  of  the  foot.  Talipes  calcaneus  develops  after  a 
time,  and  the  toes  become  claw-like,  owing  to  extension  of  the  proxi- 
mal and  flexion  of  the  second  and  third  phalanges.  There  is  anes- 
thesia along  the  back  of  the  leg  and  over  the  sole  of  the  foot. 

The  cervical  sympathetic  nerve  may  be  injured  by  wounds,  or 
compression  by  tumors  or  aneurysms.  Irritation  of  the  nerve  causes 
unilateral  sweating  of  the  head  and  face,  dilatation  of  the  pupil 
on  the  same  side,  widening  of  the  palpebral  fissure,  slight  exoph- 
thalmos, increased  intraocular  tension,  contraction  of  the  blood 
vessels  of  the  head  and  neck,  and  tachycardia.  Division  of  the 
nerve  causes  contraction  of  the  pupil,  ptosis  and  narrowing  of  the 
palpebral  fissure,  decrease  of  ocular  tension  with  recession  of  the  eye- 
ball, dilatation  of  the  vessels  of  the  head  and  neck  with  increase 
in  the  flow  of  tears,  nasal  mucus,  and  sweat,  and  bradycardia. 
Excision  of  the  cervical  sympathetic  ganglia,  or  Jonnesco's  operation, 
has  been  performed  for  epilepsy,  exophthalmic  goiter,  tic  doulou- 
reux, and  glaucoma.  An  incision  is  made  along  the  anterior  border  of 
the  sternomastoid,  the  carotid  sheath  with  its  contents  retracted 
forwards,  and  the  upper  or,  in  some  cases,,  the  entire  three  ganglia 
excised.     The  value  of  the  operation  is  not  yet  fixed. 


CHAPTER  XVIII 
MUSCLES,  TENDONS,  BURS^ 

Contusion  of  muscles  is  followed  by  swelling,  rigidity,  and  by 
late  ecchymosis  if  some  of  the  blood  vessels  have  been  injured.  Pain 
and  tenderness  are  made  worse  by  active  motion,  but  are  unaffected 
by  passive  motion,  unless  the  muscle  is  stretched  by  such  procedure. 
The  treatment  is  rest  and  relaxation  of  the  muscles,  by  splints,  posture, 
or  strapping  with  adhesive  plaster;  the  application  of  ichthyol  or 
evaporating  lotion;  and  later  massage. 

Wounds  of  muscles  gap  widely  if  they  traverse  the  muscle 
fibers.  A  wound  parallel  with  the  fibers  causes  little  or  no  separation. 
Suturing  is  readily  carried  out  in  longitudinal  or  oblique  wounds,  but 
is  often  difficult  in  transverse  wounds,  the  stitches  tearing  out  when 
approximation  is  attempted.  In  such  cases  mattress  sutures  may  be 
employed;  a  number  of  sutures  may  be  placed  in  each  end  of  the 
muscle  and  tied,  then  the  ends  of  the  sutures  in  the  upper  segment  tied 
to  those  in  the  lower  segment;  or  the  muscular  wound  may  be  cov- 
ered with  a  free  transplant  of  fascia,  which  can  be  employed  also  to 
bridge  a  gap  when  a  portion  of  the  muscle  has  been  destroyed. 
Chromicized  catgut  is  the  best  suture  material.  The  muscles  should 
be  relaxed  by  suitable  posture  or  splint,  and  massage  and  electricity 
employed  when  healing  has  been  completed. 

Strain  of  muscles  is  an  overstretching  of  the  fibres  with  possibly 
some  tearing.  Glass  arm  is  a  strain  of  the  long  head  of  the  biceps; 
lawn  tennis  arm,  of  the  pronator  radii  teres;  riders  leg,  of  the  adduc- 
tor muscles  of  the  thigh.  The  symptoms  and  treatment  are  those  of 
contusion  of  muscle. 

Rupture  of  muscles  and  tendons  usually  occurs  as  the  result  of 
great  violence  to  a  contracted  muscle,  or  as  the  result  of  a  sudden, 
powerful,  and  strongly  opposed  contraction,  but  may  follow  even 
feeble  efforts  in  muscles  degenerated  in  consequence  of  senility  or 
fevers.  Rupture  of  the  sheath  or  of  the  deep  fascia  may  result 
in  hernia  of  the  muscle,  a  protrusion  which  is  most  marked  during 
contraction,  and  which  often  disappears  during  relaxation 
of  the  muscle,  when  the  opening  in  the  aponeurosis  may  be  felt 
through  the  skin.  In  recent  cases  rest  and  relaxation  are  required. 
Later  if  the  hernia  is  large  and  causes  inconvenience,  the  opening  in 

362 


MUSCLES,    TENDONS,   BURS^ 


363 


the  sheath  may  be  sutured,  or,  if  large,  patched  with  a  transplant  of 
fascia  lata.  A  muscle  most  frequently  ruptures  at  the  junction 
with  its  tendon,  although  the  belly  itself  or  the  tendon  may  tear.  In 
some  cases  the  tendon  is  torn  from  its  attachment,  bringing  with  it  a 
portion  of  the  bone.  At  the  time  of  rupture  there  is  a  sudden  sharp 
pain,  with,  in  some  cases,  an  audible  snap.  This  is  followed  by  loss 
of  function,  tenderness,  pain  on  motion,  swelling,  and  ecchymosis. 
The  gap  may  be  felt  in  superficial  muscles.  Among  the  muscles 
and  tendons  most  frequently  ruptured  are  the  sternomastoid  (during 
labor),  rectus  abdominis,  quadriceps,  ligamentum  patellae,  tendon  of 
the  adductor  longus  (from  riding),  plantaris  (tennis  leg,  chap, 
xxxi),    long  head   of   the   biceps   cubiti    (Fig.  152),  flexor  muscles 


Fig.  152. — Rupture  of  biceps  muscle. 


or  tendons  of  the  fingers,  extensors  of  the  fingers  (mallet  finger, 
(chap.  xxxi). 

The  treatment  in  partial  ruptures  is  rest  and  relaxation;  in  large 
or  complete  ruptures  of  important  muscles  the  ends  should  be  ap- 
proximated as  described  above,  and  the  part  splinted.  Massage, 
electricity,  and  passive  motions  are  employed  after  union  has  taken 
place. 

Dislocation  of  tendons  is  most  frequent  at  the  point  where  a 
tendon  passes  along  a  bony  groove  in  order  to  change  its  direction, 
e.g.,  the  long  tendon  of  the  biceps,  and  the  tendons  about  the  wrist  and 
ankle.  It  is  usually  the  result  of  injury,  hence  may  be  accompanied 
by  a  fracture  of  a  bone  or  a  dislocation  of  a  joint,  but  it  occurs  also  as 
the  result  of  chronic  afTections  of  joints  associated  with  displacement. 


364  MANUAL    OF    SURGERY 

There  are  pain  and  weakness,  and  in  some  cases  the  dislocated  tendon 
can  be  felt,  with  the  groove  in  which  it  normally  lies.  In  dislocation 
of  the  long  head  of  the  biceps  the  head  of  the  humerus  passes  slightly 
forwards  {subluxation) . 

The  treatment  is  reduction  of  the  tendon,  relaxation  of  the  muscle, 
and  the  application  of  a  splint,  with  pressure  over  the  tendon  to  hold 
it  in  place.  If  this  treatment  fails  in  the  course  of  six  weeks  or  two 
months,  the  tendon  may  be  exposed  by  incision  and  the  edges  of  the 
the  torn  sheath  sutured  with  catgut.  This  operation  is  most  fre- 
quently indicated  in  dislocation  of  the  peroneus  longus  tendon  from 
behind  the  external  malleolus. 

Myositis,  or  inflammation  of  muscles,  may  be  acute  or  chronic. 

Acute  myositis  may  be  due  to  injuries  {traumatic  myositis),  infec- 
tion from  the  surrounding  parts,  exposure  to  cold  {rheumatic  myosi- 
tis), and  to  infectious  fevers.  The  symptoms  are  pain,  swelling, 
tenderness,  and  sometimes  edema  of  the  skin.  When  due  to  local 
infections  or  pyemia,  suppuration  follows.  Polymyositis  affects 
many  muscles,  is  of  obscure  origin,  and  strongly  resembles  trichino- 
sis, hence  the  term  pseudotrichinosis .  When  there  is  an  overproduc- 
tion of  fibrous  tissue  the  muscle  is  shortened,  thus  in  the  sternomas- 
toid  torticollis  may  be  produced,  and  in  the  forearm  Volkmann's 
contracture  {ischemic  myositis,  chap.  xxxi). 

The  treatment  is  rest,  sedative  applications,  and  constitutional 
treatment  according  to  the  general  condition  of  the  patient.  Sup- 
puration will  require  incision.  Massage  and  electricity  are  indicated 
to  prevent  muscular  contractures,  which,  when  present,  may  require 
tenotomy  or,  better,  tendon  lengthening;  resection  of  bone  to  shorten 
the  limb  also  has  been  performed  in  certain  cases. 

Chronic  myositis  results  from  the  acute  form,  or  from  syphilis, 
tuberculosis,  rheumatism,  actinomycosis,  or  the  lodgment  of  para- 
sites (trichina,  echinococcus).  It  may  cause  suppuration,  or  degen- 
eration with  fibrous  overgrowth.  In  the  latter  event  ossification  may 
occur,  particularly  in  the  vicinity  of  bone,  or  where  the  parts  are 
constantly  irritated  or  strained,  e.g.,  rider^s  bone  due  to  ossification 
of  the  upper  portion  of  the  adductor  tendons  of  the  thigh,  and 
localized  ossification  of  the  deltoid  in  soldiers.  In  myositis  ossificans 
progressiva  a  large  part  of  the  muscular  system  may  be  calcified. 
The  cause  is  not  known.  It  is  most  frequent  in  young  males,  and  is 
sometimes  associated  with  shortening  of  the  thumbs  and  great  toes. 
The  treatment  is  directed  to  the  cause.  In  localized  myositis  ossi- 
ficans the  bony  plates  may  be  excised.  In  the  progressive  form 
treatment  is  of  no  value. 


MUSCLES,    TENDONS,    BURS^  365 

Tumors  of  muscle  include  fibroma,  myxoma,  lipoma,  angioma, 
chondroma,  osteoma,  myoma,  and  most  important  of  all,  sarcoma; 
carcinoma  is  always  secondary.  A  desmoid  is  a  fibroma  or  fibro- 
sarcoma of  the  rectus  abdominis,  usually  occurring  in  women  who 
have  borne  children.  A  tumor  in  a  muscle  is  movable  i)erpendicu- 
larly  to  but  not  in  the  axis  of  the  muscle,  and  becomes  fixed  when  the 
muscle  is  contracted.     The  treatment  is  excision. 

Tenosynovitis,  thecitis,  or  inflammation  of  a  tendon  sheath,  may 
be  acute  or  chronic.  Acute  tenosynovitis  is  caused  by  injury,  strains, 
overuse,  neighboring  infections,  gout,  rheumatism,  syphilis,  gonor- 
rhea, and  the  infectious  fevers.  The  symptoms  are  swelling  and 
tenderness,  with  pain  and  fine  crepitus  upon  motion.  Suppuration 
may  occur  when  the  sheath  has  been  opened  by  a  wound,  or  when  the 
thecitis  is  secondary  to  neighboring  infections.  The  symptoms  are 
then  intensified,  the  skin  reddened,  and  constitutional  symptoms  of 
sepsis  present.  The  treatment  is  immobilization  on  a  splint,  with  the 
application  of  ichthyol  or  evaporating  lotions.  Pus  formation 
demands  incision  and  drainage,  which,  if  carried  out  early,  may 
prevent  sloughing  of  the  tendon.  Massage  and  active  and  passive 
motions  are  useful  in  the  later  stages  to  prevent  adhesions.  Sup- 
purative thecitis  of  the  finger  and  palmar  abscess  are  described  in 
chapter  xxxi. 

Chronic  tenosynovitis  may  follow  the  acute  form,  in  which  case 
the  sheath  is  distended  with  synovial  fluid.  There  are  weakness, 
swelling  and  fluctuation  along  the  tendon  sheath,  and  possibly 
crepitus.  In  most  instances  the  condition  is  tuberculous.  Tuber- 
culous tenosynovitis  may  present  the  same  signs,  or  the  swelling  may 
be  doughy  owing  to  the  thick,  pulpy  granulation  tissue  which  lines 
the  sheath.  Often  there  can  be  felt  sUpping  beneath  the  fingers 
little  rounded  bodies  (rice,  riziform,  or  melon  seed  bodies),  which  are 
laminated  masses  of  fibrin.  The  treatment  of  chronic  tenosynovitis 
is  attention  to  any  existing  constitutional  disease,  and  locally  the  use 
of  a  splint,  with  compression  or  counterirritation.  If  this  fails,  the 
sheath  may  be  opened,  its  contents  evacuated,  iodoform  emulsion 
injected,  and  the  wound  closed;  or  an  attempt  may  be  made  to  re- 
move the  diseased  sheath  by  dissection. 

Ganglion  is  a  tense  sac  connected  with  a  tendon  sheath,  and  filled 
with  a  transparent,  whitish,  jelly-like  material.  It  may  follow  an 
injury  or  strain,  and  is  then  probably  due  to  an  encarcerated  hernia 
of  the  synovial  lining  of  the  tendon  sheath;  in  other  instances  it  is  due 
to  a  localized  thecitis,  a  colloid  degeneration  of  a  synovial  fringe,  or 
perhaps,  as  some  maintain,  to  a  hyperplasia  of  the  connective  tissue 


366  MANUAL    OF    SURGERY 

followed  by  cystic  degeneration.  It  is  most  common  on  the  back  of 
the  wrist,  but  may  occur  elsewhere.  It  is  painful  and  tender  when 
increasing  in  size,  but  usually  gives  no  trouble  when  it  has  ceased  to 
grow,  except  possibly  for  some  weakness  of  the  affected  tendon.  It 
may  be  so  hard  as  to  resemble  an  exostosis.  Compound  ganglion 
is  a  tuberculous  thecitis  of  the  flexor  tendons  of  the  wrist,  projecting 
above  and  below  the  annular  ligament.  The  treatment  is  rupture  of 
the  ganglion  by  strong  pressure  with  the  thumbs,  or  by  dealing  it  a 
sharp  rap  with  a  book;  expression  of  the  contents  through  a  small 
puncture,  and  firm  pressure  for  several  days;  the  injection  of  iodin; 
or  in  recurring  cases  excision. 

OPERATIONS  ON  TENDONS 

Tenotomy,  or  division  of  a  tendon,  may  be  open  or  subcutaneous 
It  is  employed  chiefly  in  cases  of  deformity,  and  occasionally  to 
overcome  muscular  spasm,  e.g.,  cutting  of  the  tendo  Achillis  in 
fractures  of  the  leg.  The  subcutaneous  method  should  be  used  only 
in  regions  in  which  important  structures  are  not  close  to  the  tendon. 
Under  aseptic  precautions  a  sharp  pointed  tenotome  is  pushed 
through  the  skin  to  the  tendon,  and  is  then  replaced  by  a  blunt 
pointed  tenotome,  which  is  passed  over  or  under  the  tendon.  The 
tendon  is  then  made  tense  and  is  cut  by  a  sawing  motion.  The  little 
puncture  is  sealed  by  collodion.  In  the  open  method  an  incision  is 
made  over  the  tendon  and  the  section  carried  out  under  the  eye,  so 
that  there  is  little  danger  of  wounding  neighboring  structures.  The 
wound  is  then  sutured.  After  either  method  the  deformity  is  cor- 
rected, and  the  parts  are  immobilized  with  plaster-of-Paris  or  other 
form  of  splint. 

Division  of  the  sternocleidomastoid  muscle.  (See  "Torti- 
colHs.") 

The  tendo  Achillis  is  divided  subcutaneously.  With  the  foot  on 
its  outer  side  and  the  tendon  relaxed,  the  tenotome  is  inserted  about 
one  inch  above  the  os  calcis,  and  the  tendon  divided  after  it  has  been 
made  taut  by  flexion  of  the  foot. 

The  tibialis  anticus  is  divided  about  one  inch  above  its  insertion. 
The  tenotome  is  introduced  from  the  outside  and  the  section  made 
from  below  upwards. 

The  peroneal  tendons  are  cut  just  above  and  behind  the  external 
malleolus,  in  which  situation  the  synovial  sheath  is  absent.  The 
tenotome  is  introduced  between  the  bone  and  the  tendons,  which  are 
made  tense  and  severed  from  below  upwards. 


MUSCLES,    TENDONS,   BURSiE 


367 


The  tibialis  posticus  is  severed  above  the  internal  annular  liga- 
ment and  above  the  origin  of  the  synovial  sheath.  The  tenotome  is 
inserted  just  above  the  base  of  the  inner  malleolus,  between  the 


Fig.  153. 


Fig.   154. 


Fig.   155. 


Figs.   153  to  156. — Tenorrhaphy.      (Monod  and  Vanverts.) 

tendon  and  the  tibia,  and  hugs  the  bone  closely.     There  is  some 
danger  of  injury  to  the  posterior  tibial  vessels. 


A  B 

Fig.  157. — Tenorrhaphy.     (Binnie.)  Fig.   158. — Tenorrhaphy.     (Binnie.) 

The  plantar  fascia  is  divided  subcutaneously  just  in  front  of  the 
OS  calcis,  by  inserting  a  tenotome  between  the  fascia  and  the  skin 
from  the  inner  side  of  the  sole,  and  cutting  towards  the  bone. 

The  semimembranosus  and  the  semitendinosus  may  be  divided 
subcutaneously  just  above  the  knee  joint,  but  section  of  the  biceps 


368 


MANUAL    OF    SURGERY 


femoris  is  best  done  through  an  open  incision,  because  of  the  proxi- 
mity of  the  pophteal  nerve. 

Tenorrhaphy  (tendon  suture)  is  best  performed  with  chromicized 
catgut.     The  various  methods  are  shown  in  Figs.  153  to  161;  Figs. 


Fig.   159. 


Fig.   160. 


Figs.   159  to  161. — Tenorrhaphy.     (Vulpius.) 

(.  .) 


Fig.   162. — Tenorrhaphy. 
(Binnie.) 


Fig.  162a. — Tenorrhaphy.      Fig.    163. — Tenorrhaphy. 

(Binnie.) 


162  and  163  show  the  methods  for  preventing  the  tearing  out  of 
sutures.  Generally  the  distal  stump  is  easy  to  find,  but  the  proximal 
retracts,  and  in  order  to  bring  it  into  view  the  joint  or  joints  may  be 
moved  in  the  direction  which  will  relax  the  tendon  and  its  muscle, 
the   limb    massaged  or  bandaged  centrifugally,  or  slender  forceps 


MUSCLES,    TENDONS,   BURS.E 


369 


passed  up  the  sheath,  which  should  not  be  opened  any  farther  than  is 
necessary,  and,  at  the  completion  of  the  operation,  should  not  be 
sutured  if  such  produces  stricture.  To  prevent  adhesions  the  suture 
line  should  be  enveloped  with  fat.  After  tenorrhaphy  the  part 
is  splinted.     Gentle  passive  motion  should  be  started  at  the  end  of 


Fig.  164.  Fig.   165. 

Figs.  164  to  166. — Tendon  lengthening. 


Fig.  166. 

(Monod  and  Vanverts.) 


two   weeks,   but  forcible  movements,   if   needed,   postponed    until 
the  fourth  week. 

Tendon  lengthening  is  occasionally  employed  in  deformities  due 
to  shortened  tendons,  or  in  cases  in  which,  after  accidental  division 
of  a  tendon,  the  approximation  is  difficult  owing  to  retraction  of  the 


n 


Pig.   167. — Tendon  lengthening.     (Binnie.) 


Fig.  168. — Catgut  graft, 
and  Kowalzig.) 


(Esmarch 


the  ends  (Figs.  164  to  168).  When  the  ends  of  a  divided  tendon 
cannot  be  sufficiently  elongated  to  approximate  them,  the  lower  end 
may  be  sutured  to  a  neighboring  tendon  with  a  similar  function, 
or  the  upper  end  to  the  periosteum  as  near  the  normal  insertion  as 
possible;  a  graft  may  be  made  from  adjacent  fibrous  tissue,  from  a 
neighboring  tendon,  from  the  fascia  lata,  from  the  tendon  of  an 


24 


370 


MANUAL   OF   SURGERY 


animal,  or  from  silk,  catgut  (Fig.  169),  linen  thread,  or  the  osseous 
insertion  may  be  transplanted  (Fig.  170). 

Tendon  shortening  is  illustrated  in  Figs.  171  to  173. 

Tendon  transplantation  has  been  employed  for  the  relief  of 
deformities  due  to  paralyzed  muscles.     The  tendon  of  the  paralyzed 


Fig.  169. — Tendon  lengthening. 
(Binnie.) 


V'EIVil 


Pig.  170. ^Tendon  lengthening 
by  transplantation  of  osseous  inser- 
tion.     (IMonod  and  Vanverts.) 


muscle  may  be  divided,  and  its  distal  end  threaded  through  a  split 
in  an  active  tendon  and  there  sutured  (Figs.  159  to  161).  Other 
methods  are  elucidated  in  Figs.  174  to  181;  the  paralyzed  tendons 
are    shaded.     Free    transplantation,    as    described    under    tendon 


Fig.  171.  Fig.  172.  Fig.  173. 

Figs.   171  to  173. — Tendon  shortening.      (Binnie.) 

lengthening,  may  be  tried  when  a  portion  of  a  tendon  has  been 
destroyed". 

Free  transplantation  of  fascia,  usually  fascia  lata  from  the  upper 
and  outer  part   of   the  thigh,  has   been    employed   to   strengthen 


MUSCLES,    TENDONS,   BURS^ 


371 


Sutures 


Fig.   174. 


Fig.  175. 


Fig.  176. 


Fig.   177. 


Fig.  178. 


Fig.   179. 


yf^ 


If        f    f ' 


/■'J 


Pig.   180. 


Fig.  181. 


Figs.    174  to  181. — Tendon  transplantation.      (Vulpius.) 


372 


MANUAL   OF    SURGERY 


ligaments  and  joint  capsules,  to  bridge  gaps  in  muscles,  to  take  the 
place  of  tendons,  to  close  defects  in  the  dura,  pleura,  diaphragm, 
bladder,  air  passages,  and  other  hollow  viscera,  to  reinforce  the 
suture  line  in  operations  for  hernia,  to  render  joints  movable  (arthro- 
plasty), to  control  bleeding  from  and  to  prevent  the  cutting  of 
sutures  in  parenchymatous  organs,  to  occlude  the  pylorus  after 
gastroenterostomy,  to  support  prolapsed  organs,  to  cover  the  osseous 
stump  after  amputation,  and  to  act  as  a  substitute  for  suture 
material.  For  the  building  of  a  tendon  sheath  or  a  nerve  sheath 
fascia  is  unsuited,  as  it  may  produce  firm  adhesions. 

DISEASES  OF  BURSiE 


Adventitious  bursae  not  uncommonly  develop  in  situations 
habitually  exposed  to  pressure,  e.g.,  on  the 
shoulder,  under  the  scapula,  and  over  the 
internal  condyle  in  knock  knee. 

Wounds  of  bursae  differ  from  ordinary 
wounds  in  that  the  continuous  escape  of 
synovial  fluid  may  interfere  with  healing 
and  necessitate  excision  of  the  bursa  or 
destruction  of  its  lining  membrane. 

Acute  bursitis  is  usually  the  result  of 
traumatism.     A   painful  and  tender  cir- 
cumscribed swelling  forms  in  the  situa- 
tion of  a  bursa,  which  fluctuates  and  is 
Fig.  182.— Prepatellar  bursitis  frequently    the   Seat   of  a   fine    crepitus. 
(housemaid's  knee).  Suppuration  may  occur  as  the  result  of 

infection  through  a  wound  or  from  the  blood.  The  treatment  is 
rest,  the  appKcation  of  ichthyol  or  evaporating  lotions,  and  later, 
compression  to  hasten  absorption.  If  suppuration  occurs  incision 
and  drainage  are  indicated. 

Chronic  bursitis  may  follow  the  acute  form,  or  result  from 
chronic  irritation,  syphilis,  tuberculosis,  gout,  or  rheumatism.  The 
bursa  is  enlarged  and  fluctuates,  owing  to  the  eft'usion  of  serous  fluid 
within.  In  old  cases  the  walls  may  be  so  thickened  as  to  simulate 
fibroma.  In  tuberculous  cases  the  swelHng  may  be  doughy,  owing 
to  the  thick  layer  of  edematous  granulations  fining  the  cavity,  or 
rice  bodies  may  be  detected.  In  late  syphifis  there  may  be  a  gummy 
degeneration,  and  in  gout  deposits  of  urate  of  soda  {tophi). 

The  treatment  in  simple  cases  is  rest,  compression,  and  counter- 
irritation  with  bfisters  or  iodin.     If  the  effusion  persists  it  may  be 


MUSCLES,    TENDONS,   BURS^E  373 

as]>iratc(I  or  the  bursa  excised.  In  tuljerculous  cases  and  in  those 
with  thick  walls,  excision  should  be  performed.  Constitutional 
treatment  will  be  needed  in  the  presence  of  syphilis,  tuberculosis, 
gout,  or  rheumatism. 

Among  the  bursae  which  are  more  commonly  diseased  are  the 
following:  A  bursa  over  the  melatarso-phalangeal  joint  of  the  big  toe 
is  called  a  bunion  (see  "Hallux  Valgus"),  the  retro  calcaneal  bursa, 
when  inflamed,  Albert's  disease  (chap.  xxxi).  The  prepatellar  bursa 
is  often  enlarged  as  the  result  of  frequent  kneeling,  and  is  known  as 
honsemaid's  knee  (Fig.  182).  The  infrapatellar  bursa  lies  between 
the  ligamentum  patellae  and  the  tuberosity  of  the  tibia,  and  when 
inflamed  causes  a  fluctuating  swelling  on  each  side  of  the  tendon, 
which  is  more  marked  when  the  leg  is  extended.  The  symptoms  may 
be  somewhat  similar  to  a  dislocated  semilunar  cartilage,  owing  to 
the  pinching  of  the  hgamenta  alaria,  which  are  crowded  back  between 
the  bones.  Of  the  popliteal  bursce  the  one  which  lies  between  the 
gastrocnemius  and  the  semimembranosus,  and  extends  beneath 
the  inner  head  of  the  gastrocnemius,  is  most  frequently  enlarged. 
It  is  hard  and  prominent  when  the  leg  is  extended,  and  may  exhibit 
transmitted  pulsation;  when  the  leg  is  flexed  it  is  soft  and  may  be 
difficult  to  detect.  It  is  tedious  to  remove,  and,  as  it  frequently 
communicates  with  the  joint,  a  ligature  or  suture  will  be  required 
to  close  the  synovial  membrane  at  this  point.  The  iliopectineal 
{iliopsoas)  bursa,  when  enlarged,  presents  a  swelling  at  the  base  of 
Scarpa's  triangle,  under  or  to  the  outer  side  of  the  femoral  artery 
(Fig.  451).  Sometimes  the  swelling  is  reducible,  the  fluid  passing 
into  the  hip-joint  or  a  neighboring  bursa.  Pressure  of  the  bursa  on 
the  anterior  crural  nerve  may  cause  pain  running  down  the  thigh, 
which  is  often  slightly  flexed,  abducted,  and  rotated  outward.  The 
diagnosis  from  hip  disease  and  femoral  hernia  is  given  under  these 
headings.  Psoas  abscess  is  associated  with  disease  of  the  spine. 
A  neoplasm  may  closely  simulate  iliopsoas  bursitis,  and  occasionally 
can  be  distinguished  from  it  only  by  exploratory  incision.  The 
bursa  of  the  great  trochanter,  when  inflamed,  causes  abduction  and 
eversion  of  the  thigh,  and  a  swelling  which  is  most  marked  just 
behind  the  great  trochanter.  It  is  distinguished  from  coxalgia  by 
the  absence  of  restricted  movements  of  the  hip- joint.  Enlargement 
of  the  bursa  over  the  tuber  ischii  is  known  as  Weaver's  bottom,  of  the 
olecranon  bursa,  miner's  elbow.  Subacromial  (subdeltoid)  bursitis  is 
described  in  chapter  xxxi. 


CHAPTER  XIX 

BONES 

INJURIES  OF  BONES 

A  fracture  has  been  defined  as  a  sudden  solution  of  the  con- 
tinuity of  a  bone,  generally  from  external  violence. 

The  Varieties. — Fractures  are  divided  as  follows:  i.  Accord- 
ing to  the  cause,  into  traumatic  and  pathological  or  spontaneous 
(resulting  from  trivial  force  to  a  diseased  bone).  Traumatic  frac- 
tures are  subdivided,  according  to  the  nature  of  the  force,  as 
explained  below  in  the  paragraph  on  "Exciting  causes."  2.  Accord- 
ing to  the  lines  of  fracture,  into  transverse,  longitudinal,  oblique,  spiral, 
dentate,  stellate,  V-shaped,  and  T-shaped.  A  comminuted  fracture  is 
one  in  which  the  bone  is  broken  into  three  or  more  fragments,  with 
intercommunication  of  the  fracture  lines.  A  multiple  fracture  is 
one  in  which  there  is  more  than  one  fracture  in  a  bone,  the  lines  of 
which  do  not  communicate.  Fractures  of  several  different  bones  also 
are  spoken  of  as  multiple  fractures.  A  splintered  fracture  is  one  in 
which  a  splinter  of  osseous  tissue  is  broken  from  a  bone.  3.  Accord- 
ing to  the  degree  of  fracture,  into  complete,  which  extends  completely 
through  a  bone,  and  incomplete,  in  which  the  bone  is  not  completely 
divided.  A  green-stick  fracture  (infraction)  is  an  incomplete  fracture 
resulting  from  the  bending  of  a  bone,  the  osseous  tissue  of  the  convex 
side  separating  and  that  of  the  concave  side  remaining  intact.  A 
fissure  fracture  is  an  incomplete  fracture  occurring  as  a  crack,  usually 
in  the  outer  table  of  the  skull.  A  subperiosteal  fracture,  which  may 
or  may  not  extend  through  the  rest  of  the  bone,  leaves  the  periosteum 
intact.  4.  According  to  the  position  of  the  fragments,  into  impacted, 
in  which  one  fragment  is  forced  into  the  other,  and  depressed,  in  which 
the  bone  is  crushed  in.  Other  terms  used  with  reference  to  dis- 
placement are,  transverse,  rotary,  angular,  and  longitudinal  (either 
overlapping  or  separation).  5.  According  to  the  presence  or  absence 
of  a  ivound  in  the  soft  parts,  into  closed  or  simple,  in  which  there  is  no 
external  wound  in  the  soft  parts,  and  open  or  compound,  in  which 
such  a  wound  exists.  A  complicated  fracture  is  one  in  which  there 
is  injury  to  an  important  vessel,  nerve,  joint,  or  viscus.  6.  Accord- 
ing to  the  situation  of  the  fracture,  into  intraarticular  or  extraarticular, 

374 


BONES  375 

with  reference  to  a  joint,  and  intra-  or  extracapsular,  with  reference 
to  the  capsular  Hj^ament  of  a  joint.  Epiphyseal  separation  also  may 
be  put  under  this  heading. 

An  intrauterine  fracture  occurs  before  birth,  a  congenital  fracture 
at  birth. 

The  causes  of  fracture  arc  predisposing  and  exciting. 

The  predisposing  causes  are  physiological  and  pathological. 
Among  the  former  are  age,  sex,  occupation,  season  of  the  year,  and 
structure  and  position  of  the  bone.  Fractures  are  frequent  in 
infancy  because  of  the  many  tumbles  which  occur  at  this  time,  but 
owing  to  the  elasticity  of  the  bones,  the  breaks  are  often  incomplete 
or  of  the  green  stick  variety.  In  old  age  the  brittleness  of  the  bones 
is  such  that  even  a  trivial  injury  may  produce  fracture.  During 
adolescence  and  adult  life  fractures  are  more  frequent  in  the  male 
sex,  owing  to  the  greater  exposure  to  injury.  Occupations  entailing 
daily  exposure  to  injury  predispose  to  fracture.  In  winter  fractures 
are  more  frequent  because  of  the  presence  of  slippery  ice  under  foot. 
The  structure  and  position  of  certain  bones  render  them  more  liable 
to  fractures.  The  pathological  causes  are  atrophy  of  hone,  the  causes 
of  which  are  given  on  p.  442,  general  disease  of  the  osseous  system, 
such  as  osteomalacia,  rickets,  idiopathic  fragilitas  ossium,  ostitis 
fibrosa,  and  ostitis  deformans;  and  localized  disease  of  hone,  such  as 
malignant  disease,  caries,  necrosis,  actinomycosis,  syphilis,  gout, 
scurvy,  tuberculosis,  and  cysts. 

The  exciting  causes  are  external  violence  and  muscular  action,  e.g., 
fracture  of  the  patella  from  contraction  of  the  quadriceps.  The 
former  may  be  direct  (the  bone  breaks  directly  beneath  the  point 
injured),  in  which  case  the  fracture  is  usually  transverse  or  commin- 
uted, or  indirect  (the  bone  breaks  at  some  distance  from  the  point  of 
violence).  Gunshot  and  punctured  fractures  are  special  varieties  of 
direct  fractures.  Indirect  fractures  may  be  designated  according 
to  the  nature  of  the  force  as  hending  (e.g.,  fracture  of  the  clavicle 
from  a  fall  on  the  shoulder),  torsion  (e.g.,  fracture  of  the  tibia  from 
twisting  of  the  leg),  compression  (e.g.,  certain  fractures  of  the  skull, 
and  fracture  of  the  tarsus  from  a  fall  an  the  foot),  or  avulsion  frac- 
tures (e.g.,  fracture  of  the  internal  malleolus  through  the  action  of 
the  internal  lateral  ligament  when  the  foot  is  everted). 

An  intrauterine  fracture  is  the  result  of  violent  uterine  contrac- 
tions, or  of  blows  upon  the  abdomen.  ^Multiple  intrauterine  frac- 
tures occur  in  syphilis.  Congenital  fractures  result  from  uterine 
contractions,  or  more  frequently  from  the  manipulations  of  the 
obstetrician. 


376 


m:a.nual  of  surgery 


Epiphyseal  separation,  or  diastasis,  occurs  before  the  age  of 

twenty-two  (Fig.  183).  The  bones  most  frequently  affected  are  the 
humerus,  radius,  femur,  and  tibia.  As  the  end  of  a  diaphysis  is 
usually  cup-shaped  to  receive  the  convex  epiphysis,  the  deformity  is 


Fig.   183. — Time  of  bony  union  of  the  various  epiphyseal  junctions.      (Brewer.) 

often  difficult  to  reduce.  A  pure  epiphyseal  separation  is  uncommon 
except  in  infants;  in  older  children  the  Hne  of  cleavage  usually  in- 
volves at  least  a  part  of  the  end  of  the  diaphysis.  During  the  process 
of  repair  the  epiphyseal  cartilage  may  prematurely  ossify  and  thus 


BONES  377 

interfere  with  subsequent  growth.  Suppuration  occasionally  follows, 
and  jKirtial  detachment  or  sprain  of  an  epiphysis  sometimes  precedes 
tuberculous  disease.  Spontaneous  separation  is  always  the  result 
of  some  disease  of  the  epiphysis,  such  as  rickets,  scurvy,  syphilis, 
tuberculosis,  or  acute  infections. 

The  Symptoms.— Excepting  certain  cases  of  spontaneous  fracture, 
there  is  a  history  oj  injury,  at  which  time  the  patient  may  feel  some- 
thing give  way,  or  hear  a  cracking  sound.  Pain  is  severe  at  the  time 
of  injury,  but  may  be  insignificant  in  pathological  fractures.  The 
location  of  acute  tenderness  is  of  great  value  in  diagnosis.  Swelling 
quickly  supervenes,  and  within  a  day  or  two  blebs,  or  bulla),  may 
form,  the  exuded  serum  from  the  deeper  tissues  passing  beneath  the 
epidermis.  Ecchymosis  occurs  within  a  few  hours  or  not  for  one 
or  more  days,  according  to  the  depth  of  the  broken  bone  and  the 
extent  of  the  injury  to  the  soft  parts.  Loss  of  function  is  caused  by 
pain,  or  by  loss  of  mechanical  support;  it  may  be  absent  in  an  incom- 
plete or  impacted  fracture,  or  in  a  fracture  of  a  bone  whose  function 
is  supplemented  by  another  bone,  e.g.,  the  fibula.  Muscular  spasm 
is  a  common  symptom,  particularly  in  the  arm  and  thigh.  Deform- 
ity, or  change  in  the  length  or  contour  of  a  limb,  is  due  to  displace- 
ment of  the  fragments  by  the  force  of  the  injury,  by  the  weight  of  the 
limb,  or  by  muscular  action.  Preternatural  mobility  may  be  obtained 
by  grasping  the  limb  just  above  and  below  the  fracture  and  mak- 
ing pressure  in  opposite  directions,  or  by  moving  the  limb  as  a  whole. 
In  fractures  ot  the  forearm  or  leg,  the  parallel  bones  may  be  alter- 
nately pressed  together  above  and  below  the  seat  of  fracture.  A 
deceptive  sense  of  abnormal  mobility  may  be  present  in  elastic 
bones  like  the  fibula  and  ribs,  in  bone  diseases  like  rickets,  in  normal 
infants,  and  in  the  neighborhood  of  joints.  Abnormal  mobility 
may  be  absent  in  an  impacted,  an  incomplete,  or  an  intraarticular 
fracture.  Crepitus  is  a  grating  sensation  or  sound  obtained  by  rub- 
bing the  ends  of  the  bone  together.  It  may  be  absent  in  an  incom- 
plete or  an  impacted  fracture,  in  one  in  which  the  fragments  are 
greatly  overlapped  or  widely  separated,  or  in  one  in  which  soft 
tissues  lie  between  the  fragments.  It  is  dry  and  harsh,  and  thus 
differs  from  the  crackling  of  air  or  blood  beneath  the  skin,  or  the 
creaking  of  inflamed  synovial  membranes,  viz.,  those  of  joints, 
tendons,  and  bursge.  The  crepitus  of  epiphyseal  separation  is  soft  o/ 
moist. 

The  constitutional  symptoms  are  trivial  or  absent  in  simple  un- 
complicated cases.  Shock  is  usually  absent,  except  in  severe  or 
complicated  fractures.     Fracture  fever  is  an  aseptic  fever  due  to  the 


378  MANUAL   OF    SURGERY 

absorption  of  fibrin  ferment,  the  temperature  being  elevated  one  or 
two  degrees  during  the  first  two  or  three  days  or  longer,  according 
to  the  amount  of  blood  extravasated. 

The  Diagnosis. — The  injured  limb  should  be  compared  with  the 
sound  limb  by  inspection,  palpation,  and  measurement.  An  ancient 
deformity  should  not  be  mistaken  for  a  recent  one.  A  knowledge 
of  the  normal  relations  of  bony  prominences  will  aid  in  the  quick 
recognition  of  detormity.  If  a  stethoscope  is  placed  over  one  end  of 
the  bone  and  the  other  end  percussed,  the  sound  may  not  reach  the 
ear  if  a  fracture  exists.  In  many  cases,  owing  to  rigidity  of  the 
muscles,  pain,  and  fright,  a  proper  examination  can  be  made  only 
under  an  anesthetic.  In  all  cases  an  X-ray  examination  should  be 
made.  A  more  accurate  idea  of  the  amount  and  character  of  the  dis- 
placement is  obtained  by  taking  two  skiagrams,  one  at  right  angles 
to  the  other  or  by  making  stereoscopic  plates  (see  Fig.  2).  Single 
exposures,  especially  in  the  region  ot  the  elbow,  knee,  ankle,  and  in 
oblique  fractures  of  the  long  bones,  may  sometimes  show  apparently 
normal  shadows,  when  a  fracture  really  exists.  Epiphyses  cannot 
be  recognized  until  sufificiently  ossified  to  cast  shadows.  In  inter- 
preting skiagrams  the  inexperienced  may  mistake  an  ununited  epiphy- 
sis for  a  fragment  of  bone,  and  an  epiphyseal  juncture  for  a  line  of 
fracture. 

The  complications  of  fractures  are:  (i)  Those  occurring  at  the 
time  of  injury,  which  may  be  (a)  general,  i.e.,  shock,  or  (b)  local, 
such  as  sprain,  dislocation,  and  injuries  to  the  vessels,  nerves,  mus- 
cles, tendons,  or  viscera;  (2)  those  appearing  during  the  time  of 
treatment  or  later,  which  again  may  be  (a)  general,  such  as  sepsis, 
tetanus,  fat  or  clot  embolism,  hypostatic  congestion  of  the  lungs, 
delirium  tremens,  delirium  nervosum,  and  suppression  or  retention 
of  urine;  or  (b)  local,  such  as  excessive  swelling  from  effusion  of  serum 
or  extravasation  of  blood;  inflammation,  ulceration,  sloughing,  or 
gangrene,  from  swelhng,  pressure  of  splints  or  bandages,  or  from 
thrombosis;  muscular  spasm;  necrosis  of  bone;  stiffness  or  ankylosis 
of  joints;  atrophy  of  muscules,  either  from  disuse,  or  from  paralysis 
the  result  of  nerve  injury;  excessive  callus  formation,  usually  there- 
suit  of  incomplete  reduction;  tumors  of  bone;  stiffness  of  tendons  from 
thecitis;  contractures  of  muscles  from  myositis  or  neuritis;  neuralgia; 
crutch  paralysis;  persistent  edema,  due  to  vasomotor  paralysis  or 
venous  thrombosis;  vicious  union;  non-union;  delayed  union;  and 
fibrous  or  cartilaginous  union. 

Repair  of  fractures  is  analogous  to  the  repair  of  other  wounds, 
except  that  the  reparative  material  ultimately  becomes  bone  instead 


BONES  379 

of  scar  tissue.  Immediately  following  a  fracture  blood  extravasates 
between  and  around  the  fragments,  which  are  freciuently  united  by  a 
bridge  of  untorn  periosteum.  The  surrounding  blood  vessels  dilate, 
and  serum  and  leukocytes  escape  into  the  tissues.  The  connective  tis- 
sue cells  proliferate  (fibroblasts)  and  replace  the  blood  clot,  which,  dur- 
ing the  first  week  or  ten  days,  is  gradually  absorbed  and  devoured 
by  the  leukocytes.  At  the  same  time  there  occurs  a  proliferation  of 
the  osteoblasts,  which  are  found  in  the  medulla  and  the  deeper  layers 
of  the  periosteum.  This  mass  of  actively  multiplying  cells  is  vascu- 
larized from  neighboring  vessels,  becomes  calcified,  and  is  finally 
transformed  into  bone  as  the  result  of  the  activity  of  the  osteoblasts. 
If  the  osteoblasts  are  slow  in  action,  calcification  is  preceded  by  the 
formation  of  fibrous  tissue  by  the  fibroblasts,  or  in  some  instances  bone 
fails  to  form  and  the  fragments  are  united  by  fibrous  tissue  only. 
When  the  osteoblasts  are  more  active,  bony  reproduction  is  preceded 
by  the  formation  of  cartilaginous  tissue,  which  in  some  cases  is  as  far 
as  repair  extends,  the  union  being  cartilaginous  only.  During  the 
process  of  repair  the  ends  of  the  bone  become  softened  as  the  result  of 
a  rarefying  ostitis,  the  roughened  ends  being  smoothed  by  a  process 
of  absorption  and  covered  with  granulations,  which  are  probably 
derived  chiefly  from  the  medulla.  The  compact  bone  itself  is  thought 
to  take  but  little  part  in  the  process  of  repair.  The  mass  of  repara- 
tive material  which  forms  between  and  around  the  fragments  is  called 
callus.  The  callus  surrounding  the  fracture  is  called  ensheathing  or 
external  callus,  that  in  the  medullary  canal  internal  or  central  callus, 
and  that  between  the  ends  of  the  bone  intermediate  callus.  The 
ensheathing  callus  is  finally  absorbed,  although  it  may  persist  and 
interfere  with  the  motions  of  joints  or  tendons,  unite  the  bone  to  a 
neighboring  bone,  or  engulf  an  adjacent  nerve.  The  central  callus 
may  be  absorbed,  although  this  is  not  common.  Ossification  begins 
in  the  first  week  and  is  complete  in  from  ten  days  (in  the  small  bones 
of  the  face)  to  six  or  eight  weeks  (in  the  femur) . 

The  treatment  of  simple  fracture  is  (i)  reduction,  (2)  retention. 
(3)  restoration  of  function. 

In  transporting  a  patient  with  a  broken  limb  it  may  be  necessary 
to  improvise  splints  from  canes,  umbrellas,  etc.  A  fractured  humerus 
may  be  fastened  to  the  chest,  a  broken  forearm  may  be  supported 
by  pushing  a  folded  newspaper  up  the  sleeve  of  a  coat,  the  lower  limb 
may  be  tied  to  its  fellow  or  held  between  the  rolled  up  ends  of  a 
blanket.  The  Thomas  splint  has,  in  military  practice,_met  all  the 
requirements  of  transportation  in  fractures  of  the  upper  and  lower 
extremities  see  Fig.  184.  , 


38o 


MANUAL   OF    SURGERY 


(i)  Reduction,  or  setting,  of  a  fracture  should  be  performed  as  soon 
after  the  accident  as  possible.  It  is  accomphshed  by  manipulations 
to  relax  muscles  or  other  soft  structures  while  the  ends  of  the  bone 
are  being  maneuvered  into  place.  Relaxation  may  be  obtained  by 
traction;  by  extension  and  counterextension;  by  posture,  e.g.,  flexion 
of  the  leg  in  fracture  of  the  tibia;  by  tenotomy,  e.g.,  of  the  tendo 
Achillis  in  fractures  near  the  ankle;  and  by  general  anesthesia, 
which  always  should  be  employed  if  reduction  cannot  otherwise  be 
readily  affected.     In  addition  to  muscular  contraction  the  obstacles  to 

reduction  are  interlocking  of  the  frag- 
ments, separation  of  the  fragments  by 
soft  parts  or  bone,  entanglement  of  one 
fragment  in  the  fascia  or  skin,  and  impac- 
tion. In  the  last  instance  reduction  is 
contraindicated  unless  the  deformity  is  excessive. 

(2)  Retention  or  immobilization  is  maintained  by  some  form  of 
splint,  which  may  be  of  wood,  metal,  felt,  leather,  plaster-of-Paris, 
etc.  Before  the  application  of  a  splint  abrasions  should  be  covered 
with  stearate  of  zinc  powder,  and  blebs  punctured  without  removing 
the  epidermis.  The  sphnt  should  be  thickly  padded,  particularly 
where  prominent  subcutaneous  bony  points  will  rest.  As  a  general 
rule  the  joints  above  and  below  the  fracture  should  be  immobihzed. 
The  hmb  should  not  be  bandaged  beneath  the  dressing  holding  the 
splint  in  place,  unless  such  bandage  is  of  soft  material  loosely  apphed 


Fig. 


-Thomas  splint. 


Pig.    185. — Blake's  modification  of  Thomas  splint. 

for  the  purpose  of  padding.  Great  care  should  be  exercised  not  to 
make  the  bandage  too  tight,  for  fear  of  sloughing  or  gangrene,  or 
ischemic  myositis.  If  the  fingers  or  toes  are  left  exposed,  they  will 
serve  as  an  index  to  the  general  conditon  of  the  Hmb.  If  they  be- 
come cold,  blue,  or  numb,  or  if  there  is  great  pain  in  the  hmb,  the 
bandages  should  be  removed  and  the  parts  inspected. 

The  so-called  fixed  dressings  (see  section  on  bandages),  such  as 
starch,  silicate  of  soda,  and  plaster-of-Paris,  are  frequently  employed 
after  the  subsidence  of  swelling,  although  many  surgeons  apply 
them  as  a  primary  dressing.     The  dangers  of  the  latter  method, 


BONES  381 

viz.,  sloughing  or  gangrene  due  to  great  swelling  beneath  the  case, 
and  undetected  displacement  of  the  fragments,  are  prevented  by 
cutting  the  dressing  immediately  after  its  application  if  it  encases 
the  entire  limb,  removing  all  but  enough  to  form  a  trough,  or  by 
applying  the  material  as  a  large  poultice  would  be  applied  and  then 
allowing  it  to  harden. 

Plastic  splints,  such  as  cardboard,  felt,  leather,  and  gutta  percha, 
are  cut  to  the  desired  pattern,  soaked  in  hot  water  to  render  them 
pliable,  and  allowed  to  harden  while  bandaged  to  the  limb.  Gooch  's 
flexible  wooden  spHnts  consist  of  thin  strips  of  fir  glued  upon  canvas; 
they  are  flexible  transversely  and  rigid  longitudinally. 

(3)  Restoration  of  function  is  obtained  first  by  accurate  reduction 
and  the  application  of  evaporating  lotions  or  an  ice  bag  to  limit 
effusion,  and  during  the  subsequent  treatment  by  massage  and  pas- 
sive and  active  motions.  In  the  early  part  of  the  treatment  of  a 
fracture  the  patient  should  be  seen  each  day,  and  the  dressings 
removed  if  such  be  indicated;  later,  in  many  instances,  the  dressing 
should  be  done  every  two  or  three  days.  The  parts  should  be  in- 
spected, the  skin  kept  in  good  condition  by  gentle  friction  with 
alcohol,  and  in  suitable  cases  the  muscles  masseed  and  the  neigh- 
boring joints  moved,  in  order  to  prevent  atrophy  and  stiffness. 
Lucas-Championiere  advises  massage  from  the  very  beginning  in  all 
fractures  except  those  of  the  patella.  In  many  instances  in  which 
there  is  no  tendency  towards  recurrence  of  displacement  the  bone  is 
not  even  splinted,  and  active  motions  are  encouraged  at  an  early 
period.  There  is  no  doubt  of  the  value  of  massage  and  early  mobili- 
zation of  joints  during  the  treatment  of  fractures,  but  in  all  cases 
the  fragments  themselves  must  be  immobilized  and  kept  so  until 
the  callus  is  sufficiently  firm  to  obviate  all  danger  of  recurrence  of 
displacement.  Blake,  as  the  result  of  his  experience  with  gunshot 
fractures  believes  that  traction  in  the  axis  of  the  proximal  fragment  of 
the  bone,  while  in  its  position  of  relaxation,  will  provide  sufficient  force, 
through  the  tense  muscles  and  fascias,  to  maintain  the  fragments  in 
their  normal  relations.  His  suspension  and  extension  treatment  of 
fractures  is  based  upon  this  principle  see  Fig.  211. 

Some  surgeons  treat  fractures  of  the  lower  extremity,  even  as 
high  as  the  middle  of  the  femur,  by  the  ambulatory  method.  A  large 
pad  is  placed  beneath  the  sole  of  the  foot  and  a  plaster  cast  applied 
to  above  the  seat  of  fracture,  so  that  when  the  patient  walks  the 
weight  of  the  body  is  supported  by  the  limb  above  the  fracture. 

In  cases  in  which  successful  reduction  cannot  be  secured  or  main- 
tained, operative  treatment  is  indicated,  providing  aseptic  details  can 


382  MANUAL   OF    SURGERY 

be  observed  and  the  requisite  skill  is  possessed  by  the  operator; 
hence  the  more  conservative  plan  of  splint  treatment  should  be 
employed  by  one  who  does  not  possess  such  qualifications.  The 
fragments  should  be  exposed  by  a  suitable  incision  and  the  obstacle  to 
reduction  removed;  this  will  often  be  found  to  be  muscle,  fascia,  or 
other  soft  parts  between  the  fragments.  In  bringing  the  fragments 
into  alignment  Lane  uses,  in  addition  to  traction,  strong  long-handled 
forceps  (Fig.  186)  to  grasp  the  ends  of  the  bones.  Martin  has  devised 
a  method  of  traction  that  is  efficient  even  in  old  cases  with  consider- 
able shortening.  He  employs  "a  long,  strong  canvas  strip  pocketed 
in  the  middle  and  looped  at  the  ends.  The  bones  at  the  seat  of 
fracture  are  freed,  the  pocket  is  slipped  over  the  proximal  end  of  the 
distal  fragment,  the  ends  of  the  canvas  strip  are  carried  in  the  long 
axis  of  the  limb,  and  in  the  loops  is  fixed  a  cord  to  which  are  attached 
weights.  By  thumb  pressure  the  bone  is  kept  from  angling  out  of 
the  wound,  and  the  weights,  up  to  100  pounds  or  more,  are  attached 
to  the  rope.  In  from  three  to  five  minutes  the  shortening  is  over- 
come."     When  the  measures  just  mentioned  fail  it  will  be  necessary 


Fig.    186. — Lane's  forceps. 

to  saw  off  a  portion  of  each  fragment  before  approximation  can  be 
accomplished,  and  in  the  forearm  or  leg  an  equal  portion  of  the  com- 
panion bone  also  must  be  removed.  Unless  is  there  no  tendency 
for  the  bones  to  slip  out  of  place  the  fragments  must  be  held  in  posi- 
tion. Probably  the  best  method  for  this  purpose  is  transplantation 
of  bone,  the  general  principles  of  which  are  summarized  at  the  end 
of  this  chapter.  A  graft  can  be  cut  from  one  of  the  fragments  or 
from  another  bone  (e.g.,  the  crest  of  the  tibia  or  a  rib)  and  used  as  an 
intramedullary  splint.  This  is  driven  into  the  medulla  of  the  upper 
fragment,  then  pushed  into  the  medulla  of  the  lower  fragment;  if  the 
latter  maneuver  is  difficult  the  medulla  can  be  opened  by  raising  a 
portion  of  the  cortex  on  a  hinge  of  periosteum.  If  the  osseous  splint 
is  loose  it  may  be  held  in  place  by  nailing  transversely,  or,  better,  by 
passing  catgut  or  kangaroo  tendon  through  holes  drilled  in  the  frag- 
ments and  the  splint.  Another  method  which  is  rapidly  gaining  in 
favor  is  to  removed  an  oblong  piece  of  the  cortex  from  each  fragment 
with  a  chisel  or  motor-driven  saw,  the  cut  surfaces  being  beveled, 
so  that  the  grafts  will  not  fall  into  the  medullary  cavity  when  replaced, 
and  one  graft  being  cut  much  longer  than  the  other.     The  longer 


BONES 


383 


graft  is  made  to  bridge  the  line  of  fracture,  and  the  cavity  thus  left 
is  filled  with  the  shorter  graft  (Fig.  187).  Fixation  may  be  secured 
also  by  silver  wire  passing  around  the  bone  or  through  holes  bored 
in  the  bone,  by  kangaroo  tendon  or  aluminium  bronze  wire,  both  of 
which  are  ultimately  absorbed,  by  silver  or  steel  plates  which  are 
fastened  to  each  fragment  with  screws  (Fig.  188),  or  by  means  of 
nails,  screws,  ivory  pegs,  metallic  staples,  bone   ferrules,  or  intra- 


FiG.   187.  Fig. 

Fig.  187. — The  small  diagram  to  the  right  represents  the  grafts  cut  from  the  inner 
surface  of  the  tibia.  A,  from  the  upper  fragment;  B,  from  the  lower  fragment.  They 
are  reinserted  into  the  bone,  as  shown  on  the  left,  and  held  in  place  with  catgut  sutures 
traversing  the  periosteum. 

Fig.  188. — Lane's  plate,  and  Lowman's  apparatus  for  holding  the  plate  and  the 
broken  bone  in  position  while  the  screws  are  forced  into  the  bone. 

medullary  splints  of  metal,  ivory,  or  bone.  The  last  may  be  living, 
as  mentioned  above,  or  dead.  Dead  bone  may  be  decalcified, 
which  is  unnecessary,  or  simply  boiled  and  cleansed  of  medulla  and 
soft  parts.  We  have  employed  lamb  and  ox  bone  prepared  in  this 
way  for  ferrules  and  intramedullary  splints.  The  special  forms  of 
apparatus  consisting  of  long  screws  held  by  external  clamps  (Parkhill, 
Keetley,  Freeman,  Lambotte)  are  too  compHcated  and  necessitate 
leaving  the  wound  open,  thus  predisposing  to  infection.     After  the 


384  MANUAL   OF    SURGERY 

fragments  have  been  fixed  in  place  the  incision  in  the  soft  parts  should 
be  closed, -and  the  limb  immobilized  by  plaster-of-Paris  or  a  suitable 
sphnt.  The  cast  should  be  put  on  the  limb  before  the  operation  and 
anesthesia;  split  into  anterior  and  posterior  halves  after  harden- 
ing; then  applied  again  after  completion  of  the  operation,  and  bound 
with  adhesive  plaster  or  bandages.  When  non-absorbable  foreign 
material  has  been  used  to  fix  the  fragments,  its  removal  is  not  infre- 
quently demanded  after  union  has  occurred,  owing  to  the  formation 
of  sinuses. 

The  treatment  of  compound  fractures  is  that  of  the  wound  in  the 
soft  parts  and  of  the  broken  bone  itself.  The  constitutional  symp- 
toms are  more  severe  than  in  simple  fracture,  there  being  a  varying 
amount  of  shock  according  to  the  degree  of  injury,  and  later  a  higher 
rise  in  temperature,  even  when  asepsis  has  been  maintained.  In 
some  cases  the  fracture  is  non-comminuted,  the  injury  to  the  soft 
parts  slight,  the  opening  in  the  skin  small  and  comparatively  clean; 
in  such  cases  the  wound  may  be  disinfected  with  iodin  and  covered 
with  a  sterile  dressing,  the  fracture  reduced  and  immobilized,  and 
the  patient  watched  for  evidences  of  sepsis.  In  others  the  injury  is 
so  extensive  that  amputation  is  required.  The  following  remarks 
apply  to  cases  of  compound  fracture  of  the  extremities  between  these 
extremes.  The  dangers  are  hemorrhage  and  sepsis.  Severe  primary 
hemorrhage  is  temporarily  controlled  by  the  tourniquet,  and  meas- 
ures are  taken  to  react  the  patient  from  shock.  In  the  absence  of 
shock  the  patient  should  be  anesthetized  and  thorough  disinfection 
carried  out,  and  the  primary  dressing  should  be  approached  as  one 
would  an  abdominal  operation.  The  limb  should  be  shaved,  scrub- 
bed with  soap  and  water,  and  washed  with  bichlorid  of  mercury,  i 
to  1,000,  or  disinfected  with  iodin.  Devitalized  tissues,  extravasated 
blood,  tissues  into  which  dirt  has  been  ground,  completely  detached 
fragments  of  bone  and  all  foreign  bodies  should  be  removed  by  clean, 
sharp  dissection,  enlarging  the  wound  in  the  skin  as  much  as  may  be 
necessary.  Pieces  of  bone  firmly  attached  to  the  soft  parts  often 
retain  their  vitality  and  may  be  left  in  place.  If  internal  fixation  is 
desired,  only  absorbable  materials  should  be  used,  silver  wire, 
steel  plates  or  screws  should  not  be  employed.  External  fixation  by 
means  of  traction  and  splints  is  usually  adequate.  The  hemorrhage 
is  controlled  in  the  usual  way,  and  the  injuries  to  the  soft  parts 
carefully  repaired,  e.g.,  suturing  of  a  torn  nerve  or  muscle.  The 
anatomical  closure  of  the  soft  tissues  with  catgut  and  the  skin  with 
silkwormgut,  at  the  time  of  the  primary  operation,  is  the  ideal  pro- 
ceedure.     This  primary  closure  oi  compound  fractures  has  been  found. 


BONES  385 

in  military  practice,  to  be  a  safe  method  when  (i)  the  interval  of 
time  is  less  than  12  hours  (2)  it  has  been  possible  to  remove  all 
foreign  bodies  and  devitalized  tissues  (3)  and  the  wound  does  not 
contain  streptococci.  If  these  conditions  cannot  be  obtained  or 
closure  of  the  wound  is  a  mechanical  impossibility,  delayed  primary 
or  secondary  closure,  after  surgical  sterility  is  obtained,  may  be 
practiced.  The  limb  is  spHnted.  If  a  plaster  cast  is  applied,  it 
should  be  made  in  the  form  of  a  gutter  sphnt.  When  the  wound  is 
left  open  and  requires  frequent  dressings  the  suspension  apparatus 
of  Blake  is  to  be  preferred  (Tigs.  189,  211). 

Fracture  complicated  with  dislocation  is  treated  by  first  reducing 
the  dislocation  by  manipulations,  aided,  if  need  be,  by  a  splint  to 
give  sufficient  rigidity  to  the  limb;  or  through  an  incision  the  articular 
end  of  the  bone  may  be  maneuvered  into  place  by  the  fingers  or  by  a 
hook.  Some  advise  setting  the  fracture  and,  after  union  has  been 
obtained,  trying  to  reduce  the  dislocation. 

Ununited  fractures,  delayed  union,  and  non-union  are  due  to 
infection;  imperfect  immobilization;  the  presence  of  muscle  or  other 
soft  tissue  between  the  fragments;  marked  overlapping;  wide  separa- 
tion; defective  nutrition  of  the  bone  as  the  result  of  injury  to  its 
blood  supply;  general  or  local  diseases  of  bones,  such  as  are  mentioned 
among  the  pathological  causes  of  fracture  (p.  268)  ;or  to  constitutional 
diseases,  such  as  syphilis,  gout,  rheumatism,  scurvy,  or  other  affec- 
tions causing  debility.  Non-union  may  be  distinguished  from  de- 
layed union  by  the  absence  oi  pain  and  the  presence  of  voluntary 
motion  in  the  former.  These  conditions  are  most  common  in  the 
patella,  olecranon,  and  similar  situations  where  strong  muscular 
contraction  tends  to  separate  the  fragments,  and  in  the  middle  of  the 
humerus  and  upper  and  lower  thirds  of  the  femur. 

Absolute  non-union,  i.e.,  when  there  is  absolutely  no  attempt  at 
repair,  is  seldom  seen  apart  from  malignant  disease  of  bone.  In 
most  instances  the  ends  of  the  bone  become  rounded,  the  medullary 
canal  closed,  and  the  fragments  joined  by  fibrous  tissue  {fibrous 
union).  In  a  pseudoarthrosis,  or  false  joint,  the  fragments  are  held 
together  by  a  capsule  of  fibrous  tissue,  within  which  is  developed  a 
bursa  the  result  of  the  friction  of  one  bone  on  the  other,  and  the  ends 
of  the  broken  fragments  are  covered  with  cartilage. 

The  treatment  of  delayed  union  is  prolonged  immobiKzation  in 
plaster-of-Paris,  and  attention  to  the  general  health.  Some  advise 
the  induction  of  congestion  or  inflammation  by  rubbing  the  ends  of 
the  bone  together,  by  scraping  the  ends  with  a  long  and  strong  needle 
pushed  in  through  the  skin,  by  the  injection  of  a  10  per  cent,  solution 


386  MANUAL   OF    SURGERY 

of  chlorid  of  zinc,  or  by  applying  a  rubber  band  around  the  limb 
above  the  fracture.  Bier  injects  fresh  blood  between  the  fragments; 
Dilger  an  emulsion  of  periosteum,  the  periosteum  being  obtained 
from  the  patient.  The  internal  administration  of  thyroid  extract 
and  potassium  iodid  are  thought  to  encourage  callus  formation. 
Non-union  is  treated  by  resection  of  the  ends  of  the  fragments,  and 
fastening  them  together  by  one  of  the  methods  mentioned  above 
(,p.  273),  the  best  of  which  for  non-union  is  bone  transplantation. 
Codivilla  wires  the  fragments,  and  envelops  the  fracture  with  a  strip 
of  periosteum  to  the  under  surface  of  whicli  is  attached  a  thin  slice 
of  bone.  When  the  ends  are  overlapped,  and  resection  would  prove 
a  formidable  operation  owing  to  the  situation  of  the  bone,  screws  or 
pegs  may  be  inserted  into  drill  holes  which  traverse  each  fragment 
from  side  to  side. 

Vicious  union,  or  union  with  great  deformity,  is  due  to  imperfect 
reduction,  recurrence  ot  displacement,  bending  or  overproduction 
of  callus  subsequent  to  the  removal  of  splints,  or  to  bone  diseases, 
such  as  fragilitas  ossium  and  osteomalacia.  It  may  be  treated, 
in  the  early  stages  while  the  callus  is  plastic,  by  pressing  the  bones 
into  place,  and  later,  if  deformity  or  disability  is  miarked,  by  osteo- 
tomy, by  chiseling  away  projecting  areas,  or  by  resecting  the  callus 
and  fastening  the  fragments  with  bone,  wire,  plates,  etc. 

Disunited  fracture,  or  separation  after  the  fragments  have  united, 
may  occur  from  violence,  and  occasionally  during  the  progress  of  an 
exhausting  disease. 

SPECIAL  FRACTURES 

The  nasal  bones  are  usually  broken  in  their  lower  third,  the 
fracture  being  frequently  compound  through  the  skin  or  mucous 
membrane.  The  cause  is  direct  violence,  the  degree  and  direction 
of  which  determine  the  amount  and  character  of  the  displacement. 
The  nasal  septum  is  often  injured,  resulting  in  lateral  displacement, 
which  may  later  give  rise  to  nasal  obstruction.  The  symptoms  are 
pain,  swelling,  crepitus,  deformity,  and  epistaxis.  Abnormal 
mobility  may  be  fallacious  in  the  lower  third  owing  to  the  great 
mobihty  of  the  cartilages.  The  complications  are  emphysema,  cere- 
bral concussion,  fracture  of  the  neighboring  facial  bones  or  of  the 
base  of  the  anterior  fossa  of  the  skull,  and  later  suppuration  and 
necrosis  of  bone  or  cartilage. 

The  treatment  should  be  prompt,  as  the  bones  early  consolidate 
in  deformity.     In  all  cases  the  septum  should  be  examined  to  deter- 


BONES  387 

mine  whether  or  not  it  is  broken.  No  apparatus  is  needed  if  there 
is  no  deformity  or  if  the  deformity  does  not  recur  after  reduction. 
Reduction  is  accompHshed  by  external  pressure,  and  by  lifting  the 
fragments  from  within  by  means  of  a  padded,  narrow  instrument, 
such  as  a  grooved  director,  or  by  a  rubber  bag  which  is  passed  into 
the  nose  and  distended  with  air.  The  septum  may  be  straight- 
ened by  a  finger  introduced  into  either  nostril  or  by  septum  forceps. 
Either  cocain  or  ether  anesthesia  may  be  necessary.  In  depressed 
fractures  reduction  may  be  maintained  by  packing  the  nostrils  with 
gauze,  or  by  passing  a  strong  pin  (Mason's  pin)  through  the  skin, 
beneath  the  fragments,  and  making  external  pressure  by  means  of 
gauze,  held  in  place  by  figure  of-8  turns  of  silk  around  the  ends  of  the 
pin.  Lateral  displacement  requires  an  external  compress  or  molded 
splint,  held  in  place  by  adhesive  plaster,  or  an  apparatus  consisting 
of  a  metallic  band  around  the  forehead  with  a  support,  provided 
with  a  pad  and  screw  for  making  pressure,  running  down  to  one  side 
of  the  nose.  If  the  septum  is  deformed,  it  may  be  held  in  place  by 
gauze  packing,  or  by  means  of  rubber,  vulcanite  or  metallic  tubes, 
which  have  perforations  in  the  side  for  drainage,  and  which  are  made 
in  various  sizes.  Roberts  inserts  one  or  more  long  pins  into  the 
septum  in  such  a  way  as  to  press  on  the  deviation  as  the  stem  of  a 
flower  is  pressed  upon  when  pinned  to  the  lapel  of  a  coat.  In  any 
case  the  nose  should  be  sprayed  several  times  daily  with  an  antiseptic 
solution,  and  the  patient  cautioned  about  blowing  or  wiping  the 
nose.  The  prognosis  is  usually  good,  although  some  deformity  is 
very  apt  to  remain  in  bad  ases.  Union  is  complete  in  from  ten  days 
to  two  weeks. 

The  lachrymal  bone  is  rarely  broken  alone,  and  the  treatment  is 
directed  principally  to  the  neighboring  bone.  Obstruction  of  the 
lachrjTnal  duct  may  be  prevented  by  the  passage  of  a  probe. 

The  malar  bone  is  fractured  by  direct  violence,  usually  with  injury 
to  adjoining  bones.  Sometimes  the  whole  bone  is  pressed  into  the 
bones  on  which  it  rests.  The  symptoms  are  deformity,  conjunctival 
hemorrhage  when  the  orbital  surface  is  involved,  and  interference 
with  the  motions  of  the  lower  jaw  when  depression  is  sufficient  to 
encroach  upon  the  coronoid  process.  Crepitus  and  abnormal  mo- 
biHty  may  be  absent.  In  favorable  cases  the  deformitj"  can  be 
corrected  by  pressure  beneath  the  bone  within  the  mouth.  If 
this  is  unsuccessful,  particularly  in  cases  in  which  the  movements  of 
the  lower  jaw  are  impaired,  the  bone  may  be  elevated  through  an 
external  incision.  Xo  retentive  apparatus  is  required,  as  displace- 
ment does  not  recur.     The  bone  unites  in  two  weeks. 


388  MANUAL    OF    SURGERY 

The  zygoma  is  fractured  by  direct  force,  or  by  indirect  force 
when  the  malar  is  depressed.  There  is  usually  an  indentation  just 
behind  its  junction  with  the  malar  bone.  The  Ireaiment  consists  in 
the  apphcation  of  pressure  within  the  mouth  or  externally,  in  order 
to  effect  reposition.  Failing  in  this,  especially  if  the  movements 
of  the  lower  jaw  are  defective,  a  piece  of  silver  wire  may  be  passed 
through  the  skin  and  beneath  the  depressed  fragment,  in  order  to 
pull  it  into  place.  A  retentive  apparatus  is  seldom  required.  Union 
is  complete  in  two  or  three  weeks. 

The  superior  maxilla  is  usually  broken  by  direct  blows,  which  in 
most  instances  break  also  contiguous  bones.  It  may.  however,  be 
broken  by  indirect  force  through  the  chin.  The  fracture  is  almost 
always  compound  and  comminuted,  and  often  bilateral.  There  are 
pain,  great  swelling  of  the  face,  and  interference  with  mastication; 
deformity,  abnormal  mobility,  and  crepitus  are  detected  through  the 
nose,  mouth,  or  cheek.  The  complications  are  emphysema,  violent 
hemorrhage  from  the  internal  maxillary  or  its  branches,  and  injury 
to  the  lachrymal  duct,  infraorbital  nerve,  or  the  brain.  Suppuration 
and  necrosis  may  occur.  The  treatment  is  careful  disinfection,  and 
molding  of  the  bone  into  position  through  the  nose  or  mouth,  or 
through  an  external  wound  if  it  be  present.  Loose  teeth  should  be 
put  back  in  place  and  fastened  to  their  fellows  by  wire.  In  fractures 
involving  the  alveolus  the  lower  jaw  may  be  used  as  a  splint  by  means' 
of  the  Barton  or  the  Gibson  bandage,  or  an  interdental  splint  may  be 
employed.  It  may  be  necessary  to  insert  a  tube  into  the  nose  to 
maintain  its  patency.  The  nose  and  mouth  should  be  washed  several 
times  a  day  with  an  antiseptic  solution,  and  the  wounds  dressed 
daily.  Liquid  food  is  administered  through  a  nasal  tube,  or  by 
passing  it  into  the  mouth  behind  the  last  teeth.  The  bone  unites 
in  three  or  four  weeks. 

The  inferior  maxilla  is  generally  broken  by  direct  violence,  but  a 
fracture  near  the  middle  line  may  result  from  a  force  which  presses 
the  bodies  together,  and  fracture  of  the  condyle  may  follow  a  fall 
on  the  chin.  The  bone  is  most  frequently  broken  just  external  to 
the  symphysis,  owing  to  the  weakness  occasioned  at  this  point  by 
the  deep  socket  of  the  canine  tooth  and  the  mental  foramen,  just 
posterior  to  it.  As  a  rule  the  fracture  is  compound  internally  and 
not  infrequently  there  are  multiple  breaks.  The  symptoms  are 
pain,  laceration  of  the  gum  at  the  point  of  fracture,  bleeding  from 
the  mouth.  sweHing  of  the  face,  abnormal  mobihty,  crepitus, and 
deformity  as  demonstrated  by  imperfect  alignment  of  the  teeth. 
When  the  bone  is  broken  in  front  of  the  masseter,  the  posterior 


BONES  389 

fragment  is  pulled  upward  by  the  masseter  and  temporal  muscles, 
while  the  depressors  of  the  jaw  (geniohyoglossus,  geniohyoid,  anterior 
part  of  mylohyoid,  digastric,  and  platysma)  draw  the  anterior 
fragment  downwards  and  backwards.  In  fractures  of  the  neck  of 
the  condyle,  the  jaw  is  drawn  toward  the  injured  side  by  the  ptery- 
goids of  the  sound  side,  and  the  condyle  is  pulled  forward  and  inward 
by  the  external  pterygoid.  Fracture  of  the  coronoid  is  very  rare, 
and  displacement  is  usually  slight,  because  the  temporal  muscle  is 
attached  farther  down  on  the  inner  than  on  the  outer  side;  if  the 
fibres  of  attachment  are  torn  the  process  is  drawn  upward  by  the 
temporal  muscle.  The  complications  are  suppuration,  and  necrosis 
of  bone,  with  the  ills  that  they  may  produce,  e.g.,  cervical  aden- 
itis, and  digestive  or  pulmonary  disorders  from  swallowing  or  inhaling 
foul  discharges.  Fracture  of  the  base  of  the  skull  may  be  produced 
if  the  condyles  are  driven  forcibly  upwards. 

The  treatment  consists  in  reduction  by  direct  pressure,  immo- 
bilization, and  careful  and  frequent  cleansing  of  the  mouth.  In 
cases  in  which  there  is  little  tendency  to  displacement,  sufficient 
immobilization  may  be  obtained  by  a  molded  chin  piece  (Fig.  195) 
of  felt,  cardboard,  leather,  or  thick  flannel  impregnated  with  plaster- 
of-Paris,  the  chin  cup  being  held  in  place  by  a  Barton  or  a  Gibson 
bandage.  If  the  displacement  tends  to  recur,  and  this  is  true  in  the 
large  majority  of  cases,  the  adjoining  teeth,  it  not  loose,  may  be  tied 
together  with  wire,  or  fastened  by  Angle's  bands,  which  are  thin 
pieces  of  metal  that  are  clamped  about  several  teeth  in  each  jaw  by 
means  of  a  screw,  the  jaws  being  held  together  by  wire  or  silk  running 
from  the  clamps  on  the  lower  jaw  to  those  on  the  upper  jaw.  Ham- 
mond's splint  consists  of  a  wire  frame  work  which  surrounds  all  the 
teeth  of  the  lower  jaw  and  which  is  fastened  in  place  at  several 
points  by  wire  running  between  the  teeth.  In  many  instances 
accurate  apposition  can  be  obtained  only  by  wiring  the  jaw  itself,  or 
far  better,  with  an  interdental  splint.  Interdental  splints  are  made 
of  vulcanite,  hard  rubber,  or  metal,  from  a  plaster-of-Paris  cast  of 
the  teeth;  they  can  be  made  only  by  a  skilled  dentist  (Fig.  190).  An 
impression  of  the  teeth  is  first  taken  by  a  dental  modeling  compound, 
which  is  softened  by  heat  and  allowed  to  harden  on  the  teeth.  A 
plaster  cast  of  the  two  jaws  is  made  from  this  mold,  the  cast  of  the 
lower  jaw  severed  at  the  point  of  fracture,  the  displacement  in  the 
cast  corrected,  and  an  interdental  splint  made  from  the  plaster  cast. 
Bars  curving  backwards  over  the  cheeks  are  sometimes  attached  to 
support  a  bandage  passing  under  the  chin,  so  that  the  jaw  will  be 
held  in  place  even  when  the  mouth  is  open  (Fig.  189).     Moriarty 


39° 


MANUAL    OF    SURGERY 


fastens  a  metallic  chin  piece  to  these  side  bars  by  several  vertical 
supports.  Matas  has  constructed  an  adjustable  metallic  interdental 
splint,  which  may  be  applied  by  any  medical  man  without  special 
dental  skill.  The  spUnt  is  a  sort  of  clamp  which  holds  the  jaw  be- 
tween a  mouth  piece  and  a  chin  cup.  It  is  made  in  three  sizes,  the 
smallest  for  children,  the  medium  for  youths,  and  the  largest  size  for 
adults;  the  chin  cup  may  be  adjusted  to  various  degrees  of  progna- 


FiG.    189. — Kingsley's  interdental  splint.      (Brophy  after  Kingsley.) 


thism  by  a  sliding  joint  (Fig.  191).  If  the  teeth  are  loose,  the  gutter 
of  the  mouth  piece  may  be  filled  with  a  dental  modeling  composition. 
In  any  case  the  mouth  and  teeth  should  be  frequently  cleansed  and 
irrigated  with  a  mild  antiseptic  solution.  If  inadvisable  to  open  the 
mouth,  the  patient  may  be  fed  as  described  under  fracture  of  the 
upper  jaw.     Fractures  of  the  coronoid  process  and  the  condyle  are 

treated  by  a  Barton  or  a  Gibson 
bandage. 

The  hyoid  bone  may  be  frac- 
tured by  constriction,  such  as 
occurs  in  throtting  and  hanging. 
The  symptoms  are  pain,  swelling, 
deformity,  bleeding  from  the 
mouth,  and  interference  with 
breathing,  speaking,  or  swallow- 
ing. Abnormal  mobihty  and 
crepitus  are  present  in  a  few  cases. 
The  treatment  consists  in  the  correction  of  the  deformity,  if  possible, 
by  a  finger  in  the  mouth  and  the  hand  externally,  and  the  appHca- 
tion  of  a  molded  cardboard  splint  to  the  neck.  The  head,  neck, 
and  lower  jaw  may  be  immobilized,  and  the  patient  fed  by  rectum; 
talking  is  forbidden.  The  bone  unites  in  four  weeks.  Edema  of  the 
glottis  may  demand  intubation  or  tracheotomy. 

The  laryngeal  cartilages  may  be  fractured,  particularly  in  old  age 


Fig.  190. — Band  splint  to  embrace  four 
teeth,  two  on  each  side  of  fracture. 
(Brophy.) 


BONES  391 

owing  to  the  deposition  of  lime  salts.  The  symptoms  are  similar  to 
those  of  fracture  of  the  hyoid  bone,  except  that  dyspnea  and  inter- 
ference with  the  voice  are  more  marked  and  emphysema  more 
common.  The  treatment  is  similar  to  that  of  fracture  of  the  hyoid 
bone. 

The  ribs  may  be  broken  by  direct  violence,  or  by  indirect  vio- 
lence, e.g.,  compression  of  the  chest,  in  which  case  the  rib  breaks  at 
its  most  convex  part,  or  near  the  angle.  In  a  few  cases  violent 
muscular  action,  such  as  occurs  in  coughing  and  straining,  is  respon- 
sible for  the  accident.     In  earlv  life  the  ribs  are  verv  elastic  and  in- 


PlG.  191. — The  Matas  splint  for  fracture  of  the  lower  jaw.  The  spUnt  consists  of 
the  followng  detachable  parts;  (a)  a  mouth  piece  of  soft  metal  (block  tin);  (b)  a  clamp 
adjusted  and  tightened  with  a  screw;  (c)  a  chin  plate  (of  perforated  aluminiim),  which 
can  be  moved  backward  or  forward  by  sliding  on  the  lower  limb  of  the  clamp.  This  is 
fixed  and  held  in  place  by  a  thumb-screw. 

complete  fracture  is  not  uncommon.  As  a  rule  more  than  one  rib  is 
broken,  those  suffering  most  frequently  being  from  the  fifth  to  the 
ninth,  as  the  upper  ribs  are  better  protected  and  the  lower  ribs  more 
movable.  The  fracture  may  be  compound  into  the  lung  or  through 
the  skin.  The  symptoms  are  localized  pain  increased  by  movements 
of  the  chest  or  pressure  over  the  sternum,  grunting  respirations, 
suppressed  cough,  emphysema  if  the  lung  is  wounded,  and  rarely 
deformity  or  abnormal  mobility.  Crepitus  is  frequently  absent; 
it  is  obtained  by  placing  the  hand  or  the  ear  over  the  point  of  greatest 
tenderness  while  the  patient  takes  a  full  breath,  or  by  alternately 
pressing  on  the  bone  on  either  side  of  the  fracture.     Hemoptysis 


392  MANUAL    OF    SURGERY 

indicates  injury  to  the  lung.  The  complications  are  injury  to  the 
heart,  lung,  diaphragm,  liver,  spleen,  and  colon,  and  hemothorax, 
pneumothorax,  pleurisy,  pneumonia,  bronchitis,  and  empyema. 

The  treatment  is  immobiHzation  of  the  affected  side  of  the  chest 
with  adhesive  plaster.  In  the  male  the  chest  should  be  shaved  and  a 
piece  of  lint  placed  over  the  nipple.  Adhesive  plaster  strips,  three 
inches  wide  and  long  enough  to  extend  about  three-fourths  around 
the  chest,  are  applied  from  below  upwards  during  expiration,  each 
strip  overlapping  the  preceding  one  (Fig.  195).  The  dressing  is 
changed  once  a  week,  and  discarded  at  the  end  of  three  weeks,  or 
later  if  there  is  much  pain.  If  strapping  increases  the  pain,  it  should 
not  be  employed,  as  the  ends  of  the  bone  are  probably  driven  in- 
wards; these  cases  should  be  confined  to  bed  with  a  compress  between 
the  shoulders.  In  the  presence  of  marked  displacement  which  is 
irreducible  by  external  manipulations,  the  deformity  may  be  cor- 


FiG.  192. — The  Sayre  dressing  for  frac-       Fig.  193. — The  Sayre  dressing  for  frac- 
ture of  the  clavicle;  posterior  view.  ture  of  the  clavicle;  anterior  view. 

rected  through  an  incision,  and  the  fracture  immobilized  by  suture. 
The  patient  should  be  guarded  from  draughts,  and  sedative  expec- 
torants employed  if  there  be  cough. 

The  costal  cartilages  may  be  broken,  or  separated  from  the  ribs  or 
sternum.  The  symptoms  and  treatment  are  those  of  fracture  of  the 
rib. 

The  sternum  is  usually  fractured  at  or  near  the  junction  of  the 
manubrium  with  the  gladiolus,  as  the  result  of  direct  violence, 
although  it  may  be  broken  by  indirect  force  from  excessive  extension 
or  flexion  of  the  body,  such  as  occurs  in  fractures  of  the  spine,  and  by 
muscular  action  in  the  same  way  that  the  ribs  may  be  broken.  The 
upper  fragment  passes  behind  the  lower  fragment,  sometimes  pro- 
ducing severe  dyspnea  and  occasionally  injury  to  the  aorta.  The 
symptoms  are  pain,  deformity,  abnormal  mobihty,  crepitus,  forward 
bending  of  the  body,  and  in  many  cases  dyspnea  and  cough.  Com- 
plications are  frequent,  there  usually  being  fractures  of  the  ribs  and 


BONES  3Q3 

spine,  and  often  injuries  to  the  thoracic  viscera;  aneurysm  of  the 
aorta,  mediastinitis,  and  necrosis  of  the  sternum  are  late  complica- 
tions. 

The  treatment  is  rest  in  bed,  with  a  compress  between  the  shoul- 
ders, and  a  broad  strip  of  adhesive  plaster  carried  across  the  chest 
over  the  fracture.  Reduction  may  sometimes  be  accomplished  by 
extending  the  spine  and  making  pressure  on  the  lower  fragment 
while  the  patient  breathes  deeply.  If  this  fails  and  there  is  dyspnea 
due  to  the  depression,  the  displacement  may  be  corrected  and  the 
fragments  fixed  in  position  through  an  external  incision.  Union  is 
complete  in  five  or  six  weeks. 

The  clavicle,  with  the  possible  exception  of  the  radius,  is  broken 
more  frequently  than  any  other  bone  in  the  body,  owing  to  its 
slenderness,  its  exposed  position,  and  to  its  transmitting  the  force  of 
blows  or  falls  from  the  upper  extremity  to  the  trunk.  Consequently 
the  usual  cause  of  fracture  is  indirect  violence,  although  direct 
violence  also  is  responsible  for  a  certain  number  of  cases.  The 
injury  is  most  frequent  in  children,  and  is  then  often  of  the  green- 
stick  variety.  The  fracture  may  be  located  at  the  sternal  end 
(unusual);  just  external  to  the  middle,  which  is  the  usual  situation, 
because  it  is  here  that  the  two  curves  of  the  clavicle  meet,  that  the 
bone  is  most  slender  and  that  fewer  muscles  are  attached;  between 
the  coracoclavicular  ligaments,  in  which  case  there  is  little  displace- 
ment; or  at  the  acromial  end,  at  which  point  too,  the  displacement 
may  be  sUght.  The  symptoms  are  those  of  fracture  in  general.  The 
patient  supports  the  elbow  with  the  hand  of  the  uninjured  side,  and 
bends  the  head  toward  the  affected  clavicle  to  relax  the  sternomas- 
toid,  which  pulls  on  the  inner  fragment  only.  The  shoulder  with 
the  outer  fragment  is  displaced  downwards,  inwards,  and  forwards, 
owing  to  the  weight  of  the  extremity  and  the  contraction  of  the 
subclavius  and  muscles  of  the  axillary  folds,  viz.,  pectoralis  major 
and  minor,  teres  major,  latissimus  dorsi.  The  inner  fragment 
ascends  slightly,  as  the  result  of  the  action  of  the  sternomastoid. 
The  complications  are  injuries  to  the  brachial  plexus,  subclavian 
vessels,  pleura,  and  lung. 

The  treatment  which  gives  the  least  deformity  is  the  placing  of 
the  patient  upon  a  firm  mattress,  with  a  pad  between  the  scapulae, 
a  shot-bag  on  the  affected  shoulder,  and  the  arm  bound  to  the  chest 
with  upw^ard  pressure  on  the  elbow.  Union  is  usually  firm  in  three 
or  four  weeks,  when  the  patient  may  be  allowed  to  get  up  with  the 
arm  in  a  sling.  But  patients  do  not  often  select  this  form  of  treat-' 
ment.     In  an  incomplete  fracture  with  little  deformity  a  sling  for  the 


394 


MANUAL    OF    SURGERY 


forearm  is  all  that  is  needed.  Reduction  is  easy  to  accomplish  by 
carrying  the  shoulder  backwards,  outwards,  and  upwards,  but  in 
ambulatory  cases  is  very  difficult  to  maintain.  The  Sayre  dressing 
is  one  of  the  best  for  this  purpose.  Two  strips  of  adhesive  plaster 
three  or  four  inches  wide,  and  long  enough  to  extend  around  the  chest 
one  and  one-half  times,  are  prepared.  Lint  powdered  with  zinc 
stearate  is  placed  in  the  fold  of  the  elbow  and  between  the  arm  and 
the  chest.  A  collar  of  lint  as  wide  as  the  adhesive  strip  is  placed 
about  the  arm  just  below  the  axilla,  and  over  this  is  applied  the  end  of 
one  of  the  strips  of  plaster,  so  as  to  form  a  loop;  the  strip  is  now  used 

to  pull  the  arm  backwards,  and 
is  fastened  around  the  chest  (Fig. 
192).  The  hand  of  the  affected 
side  is  placed  on  the  opposite 
shoulder,  and  the  second  strip  of 
plaster,  with  a  hole  for  the  point 
of  the  elbow,  is  run  from  the 
back  of  the  sound  shoulder, 
under  the  elbow  of  the  affected 
side,  over  the  sound  shoulder,  to 
the  back  (Fig.  193),  thus  drawing 
the  elbow  forwards  and  upwards, 
and,  with  the  aid  of  the  first  strip, 
which  acts  as  a  fulcrum,  forcing 
the  shoulder  backwards  and  out- 
wards. A  pad,  held  in  place  by 
a  strip  of  adhesive  plaster,  may 
be  placed  just  above  the  clavicle 
to  press  the  fragment  downwards. 
The  Velpeau  bandage  is  fre- 
quently employed,  that  of  De- 
sault  is  seldom  used  (see  bandaging).  A  posterior  figure-of-8 
bandage,  pulling  the  shoulders  backwards,  may  be  combined  with  an 
axillary  pad,  and  a  forearm  sling  which  pulls  the  elbow  inwards  and 
upwards.  The  fragments  may  be  wired  when  the  fracture  is  compound 
or  multiple,  or  when  there  is  great  deformity,  pressure  upon  nerves  or 
blood  vessels,  or  a  sharp  fragment  which  threatens  to  perforate  the 
skin.  The  prognosis  is  very  good  concerning  the  function  of  the  arm, 
but  after  a  complete  fracture  between  the  rhomboid  ligament  on  the 
inside  and  the  coracoclavicular  ligament  on  the  outside,  deformity 
to  a  greater  or  lesser  degree  is  sure  to  persist. 

The  body  of  the  scapula  is  broken  by  direct  violence.     The 


Fig.  194. — Fractures  of  the  neck  of  the 
scapula.  A,  Through  the  glenoid  fossa; 
B,  through  the  anatomical  neck;  C, 
through  the  surgical  neck.  (Rose  and 
Carless.) 


BONES  395 

symptoms  are  swelling,  abnormal  mobility,  crepitus,  and  pain  upon 
abduction  of  the  arm  or  rotation  of  the  scapula.  Deformity  is 
usually  absent.  The  treatment  is  immobilization  of  the  shoulder  and 
arm  by  a  bandage  passing  around  the  chest,  and  a  sling  for  the  fore- 
arm. Strapping  the  chest  in  a  way  somewhat  similar  to  that  used 
for  the  ribs  also  is  useful. 

The  surgical  neck  of  the  scapula,  when  broken  (Fig.  194),  causes 
flattening  of  the  shoulder,  prominence  of  the  acromion,  lengthening 
of  the  arm  (from  acromion  to  external  condyle),  a  swelling  in  the 
axilla,  and  crepitus  on  rotating  or  raising  the  arm.  The  deformity 
is  reduced  by  pressing  upwards  on  the  elbow  and  on  the  axillary 
swelling,  a  pad  placed  in  the  axilla,  and  a  Velpeau  bandage  applied. 
The  dressing  may  be  removed  in  five  weeks. 

The  anatomical  neck  of  the  scapula  or  the  glenoid  cavity  may  in 
rare  instances  be  broken,  resulting  in  slight  lengthening  of  the  arm 
and  a  fullness  of  the  axilla.  Crepitus  may  be  obtained  by  pushing  up 
on  the  elbow  or  by  rotating  the  arm.  The  treatment  is  that  for 
fracture  of  the  surgical  neck. 

The  acromion  process  is  broken  by  direct  violence.  The  symp- 
toms are  pain,  loss  of  abduction  of  the  arm,  flattening  of  the  shoulder, 
and  abnormal  mobihty  and  crepitus,  obtained  by  pushing  upwards 
on  the  elbow.  The  treatment  consists  in  pushing  the  elbow  upwards, 
thus  supporting  the  acromion  process  with  the  head  of  the  humerus. 
The  position  is  maintained  for  four  weeks  by  a  Velpeau  bandage  or 
the  third  roller  of  Desault. 

The  coracoid  process  may  be  broken  by  direct  violence  or  muscu- 
lar action,  but  the  accident  is  rare.  Deformity  is  not  noticed,  but 
crepitus  and  abnormal  mobility  are  often  obtainable.  A  Velpeau 
bandage  should  be  worn  for  four  weeks. 

The  htunerus  may  be  broken  through  the  upper  extremity,  the 
shaft,  or  the  lower  extremity. 

The  upper  extremity  of  the  humerus  may  be  broken  at  the 
anatomical  neck,  at  the  surgical  neck,  or  through  the  head  of  the  bone 
or  the  tuberosities,  or  the  upper  epiphysis  may  be  separated. 

The  anatomical  neck  of  the  humerus  is  broken  by  direct  violence 
applied  to  the  shoulder,  particularly  in  the  aged.  The  line  of  fracture 
may  be  wholly  wdthin  the  capsule  of  the  joint  (intracapsular  frac- 
ture), but  in  many  instances  it  extends  beyond  the  capsule.  Impac- 
tion is  frequent,  and  even  when  the  head  of  the  bone  is  movable  on 
the  shaft  it,  as  a  rule,  still  remains  attached  to  the  capsule  at  some 
parts,  so  that  necrosis  is  not  as  frequent  as  one  might  expect.  The 
symptoms  are  pain,  swelling,  broadening  of  the  neck  of  the  bone. 


396 


MANUAL    OF    SURGERY 


interference  with  the  functions  of  the  shoulder,  sHght  shortening 
of  the  arm  from  acromion  to  external  condyle,  and  in  unimpacted 
cases  abnormal  mobility  and  crepitus;  the  last  two  symptoms  are 


Fig.  195. — I.  Fracture-box.  2.  Double  inclined  plane  fracture-box.  3.  Jaw-cup 
unfolded.  4.  Jaw-cup  (folded).  5.  Anterior  angular  splint.  6.  Internal  angular 
splint.  7.  Bond  splint.  8.  Shoulder-cap.  9.  Dupuytren  splint  in  Pott's  fracture. 
10.  Agnew  splint  for  fracture  of  the  metacarpus.  11.  Agnew  splint  for  fracture  of  the 
patella.  12.  Agnew  splint  applied.  13.  Strapping  the  chest  in  fractured  ribs.  14. 
Extension  apparatus  in  fracture  of  the  femur.  15,  16.  Adhesive  strips  for  extension 
apparatus.     (DaCosta.) 


obtained  by  grasping  the  head  of  the  bone,  and  gently  rotating  the 
humerus  by  manipulating  the  elbow  with  the  other  hand.  These 
movements  should  never  be  violent,  because  of  the  danger  of  sepa- 


BONES  397 

rating  an  impaction,  or  tearing  away  that  portion  of  the  capsule 
which  remains  attached  to  the  head. 

The  treatment  in  impacted  fracture  is  a  sling  for  the  limb,  gentle 
massage  from  the  beginning,  and  early  passive  motion.  In  other 
cases  a  pad  should  be  placed  in  the  axilla,  a  cap  of  cardboard  or  felt 
(Fig.  195)  molded  to  the  shoulder,  and  the  arm  and  forearm  (flexed 
to  a  right  angle)  bandaged  to  the  side.  Union  may  not  occur  for 
five  or  six  weeks  or  longer.  The  prognosis  is  good  as  far  as  union 
is  concerned,  but  stiffness  of  the  joint,  atrophy  of  the  muscles,  and 
persistent  pain  are  common  sequelae. 

The  surgical  neck  of  the  humerus  is  usually  broken  by  direct 
violence,  occasionally  by  indirect  violence,  rarely  by  muscular 
action.  The  symptoms  are  pain  (which  may  be  reflected  along  the 
large  nerves  from  pressure),  abnormal  mobility,  crepitus,  shortening 
of  the  limb  (one  inch  or  more) ,  a  depression  just  below  the  shoulder 
and  abduction  of  the  elbow  from  the  side 
of  the  body.  The  upper  end  of  the  lower 
fragment  passes  into  the  axilla,  owing  to 
the  inward  traction  of  the  muscles  at- 
tached to  the  bicipital  groove  (pectoralis 
major,  teres  major,  latissimus  dorsi) ,  and 
the  upward  pull  of  the  deltoid,  biceps, 
coracobrachialis,  and  triceps;  the  upper      ^i^-  196.— A, normal  shoulder; 

B,    dislocation    of    shoulder;     C, 

fragment  may  be  abducted  by  the  sup-  fracture    of    surgical    neck    of 

raspinatUS,  but  there  is  Httle  or  no  rotary   humerus.     (Rose  and  Carless.) 

displacement,  because  the  subscapularis  in  front  and  the  teres  minor 
and  infraspinatus  behind  nearly  or  quite  balance  each  other;  if 
impaction  be  present  the  signs  are  obscure  and  the  diagnosis  diflficult. 
The  deformity  resembles  that  of  dislocation  of  the  shoulder,  but  in 
the  former  the  depression  is  lower  (Fig.  196),  the  head  of  the  bone 
is  in  place,  and,  when  the  arm  is  rotated,  there  is  immobility  of  the 
head  with  crepitus.  The  complications  are  injuries  of  the  axillary 
vessels  or  nerves,  particularly  the  circumflex  nerve,  which  passes 
around  the  bone  at  or  near  the  line  of  fracture. 

The  treatment  may  require  only  that  of  fracture  of  the  ana- 
tomical neck.  The  triangular  axillary  splint  provides  a  position  of 
complete  muscular  relaxation  and  immobilizaton  of  the  fragments. 
Reduction  is  accomplished  by  extension  counterextension,  and  manip- 
ulation. Extension  may  be  maintained  during  the  course  of  treat- 
ment by  attaching  a  weight  to  the  elbow;  also  The  Thomas  splint 
or  the  extension  and  suspension  apparatus  of  Blake  (Fig.  198). 
Gentle  passive  motions  are  begun  at  the  end  of  three  weeks.     The 


398 


MANUAL    OF    SURGERY 


prognosis  is  good,  but  in  the  old  and  rheumatic  stiffness  and  pain 
are  frequent  legacies. 

The  head  of  the  humerus  may  be  broken  by  direct  violence,  but 
the  accident  is  rare,  and  seldom  recognized  without  the  aid  of  the 
X-rays.     It  is  treated  by  immobilizing  the  shoulder. 

The  greater  tuberosity  may  be  bi'oken  by  direct  violence,  or 

torn  from  the  humerus  by  contraction 
of  the  attached  muscles  (supra-  and  in- 
fraspinatus, teres  minor).  The  injury 
may  complicate  fracture  through  the 
neck  or  anterior  dislocation  of  the 
shoulder.  The  symptoms  are  pain, 
swelhng,  crepitus,  and  loss  of  outward 
rotation  of  the  arm.  If  completely  de- 
tached, the  fragment  is  drawn  upwards 
and  backwards  by  the  supra-  and  in- 
fraspinatus muscles.  The  treatment  is 
that  of  fracture  of  the  anatomical  neck 
or,  if  there  is  much  separation,  incision 
with  wiring  or  pegging  the  fragment  in 
place.  A  theoretically  correct  but  im- 
practicable plan  is  to  place  the  patient 
in  bed  and  hold  the  arm  abducted  and 
rotated  outward  by  means  of  sand  bags. 
The  lesser  tuberosity  is  said  to  have 
been  fractured  but  three  times. 

Separation  of  the  upper  epiphysis 
of  the  humerus  occurs  before  the 
twentieth  year,  as  the  result  of  direct 
violence,  but  the  accident  is  not 
common.  The  symptoms  resemble 
those  of  fracture  of  the  surgical  neck, 
except  that  the  crepitus  has  a  much 
softer  quality.  Displacement  is  often  slight  owing  to  the  presence 
of  an  untorn  periosteal  bridge.  The  treatment  is  that  of  fracture  of 
the  surgical  neck.  Reduction  is  sometimes  difficult,  owing  to  the 
conical  shape  of  the  upper  end  of  the  shaft  and  the  smallness  of 
the  upper  fragment,  but  is  of  the  greatest  importance,  because  of  the 
danger  of  arrest  of  growth  in  the  Hmb.  It  is  best  accompHshed  by 
slight  rotation,  and  by  bringing  the  elbow  forwards  and  upwards,  as 
the  untorn  periosteal  bridge  is  usually  situated  on  the  posterior 
surface  of  the  bone. 


Fig.  197. — Skiagraph  of  fracture 
of  the  humerus  above  the  insertion 
of  the  deltoid.  (Pennsylvania 
Hospital.) 


BONES 


399 


The  shaft  of  the  humerus  is  frequently  broken,  usually  by  direct 
violence,  but  also  by  indirect  force,  and  occasionally  by  muscular 
action.  The  symploms  are  those  of  fracture  in  general.  The 
displacement  depends  on  the  situation  of  the  fracture.  When  the 
bone  breaks  above  the  insertion  of  the  deltoid,  the  upper  fragment 
is  drawn  inwards  by  the  muscles  attached  to  the  bicipital  groove 
(pectoralis  major,  teres  major,  latissimus  dorsi),  the  lower  fragment 
upwards  and  outwards  by  the  deltoid  (Fig.  197).  When  the  fracture 
is  below  the  insertion  of  the  deltoid,  the  usual  situation,  the  upper 


Fig.   198. 


-Blake's  suspension  and  extension  dressing  applied  to  fracture  of  the  arm. 
In  bed.      (American  Ambulance.) 


fragment  is  drawn  outwards  by  the  deltoid,  and  supraspinatus, 
forward  by  the  coracobrachialis  and  anterior  portion  of  the  deltoid 
while  the  lower  passes  upwards  and  inwards  (Fig.  198).  The  com- 
plications are  injuries  to  the  brachial  vessels  and  the  nerves,  partic- 
ularly the  musculospiral,  which  lies  close  to  the  bone;  non-union  is 
more  frequent  here  than  in  any  other  bone  in  the  body,  probably 
owing  to  the  method  of  treatment,  in  which,  as  the  result  of  im- 
perfect fixation  of  the  shoulder,  movements  at  the  seat  of  fracture 
are  not  entirely  prevented. 

The  treatment  is  reduction  by  extension  and  direct  pressure. 
If    prolonged     extention    is    necessary,     the    dressing    of    Blake, . 


400  MANUAL    OF    SURGERY 

Figs.  198-199  should  be  used.  The  triangular  axillary  splint, 
provides  the  best  method  of  immobilization  in  a  sling.  The 
dressings  are  removed  in  five  or  six  weeks  if  the  fracture  is 
firm. 

The  lower  extremity  of  the  humerus  may  be  broken  above  the 
condyles  {siipracondyloid  fracture) ,  above  and  between  the  condyle 
{T-  or  Y-  shaped  fracture),  or  through  either  condyle  or  epincondyle, 
or  the  lower  epiphysis  may  be  separated. 


Fig.   199. — Blake's  suspension  and  extension  dressing  applied  to  fracture  of  the  arm. 
Out  of  bed.      (American  Ambulance.) 

The  examination  of  an  injured  elbow  should  be  made  with  the 
greatest  care,  in  order  to  exclude  fracture  and  dislocation.  General 
anesthesia  is  often  necessary  in  fracture,  to  permit  diagnosis  and 
facilitate  reduction,  and  the  X-ray  should  be  used  in  all  doubtful 
cases.  The  injured  elbow  is  compared  with  that  of  the  opposite 
side  while  both  are  in  a  similar  position.  There  are  four  landmarks 
whose  position  must  be  determined  viz.,  the  two  condyles,  ole- 
cranon, and  the  head  of  the  radius.  In  the  normal  extended 
elbow  the  tip  of  the  olecranon  is  a  trifle  below  the  intercondyloid 
line,  but  nearer  the  internal  than  the  external  condyle,  while  the 
three  points  are  in  a  plane  parallel  to  the  back  of  the  arm  when  the 
forearm  is  flexed  to  a  right  angle.     The  intercondyloid  line  is  per- 


BONES 


401 


pendicular  to  that  of  the  axis  of  the  arm.  The  head  of  the  radius  is 
immediately  below  the  outer  condyle,  at  the  bottom  of  a  dimple, 
which  is  easily  seen  when  the  arm  is  extended.  Normally  the  axis 
of  the  supinatcd  and  extended  forearm  is  directed  away  from  the 


Fig.   200. — Fracture  of  the  humerus  below  the  insertion  of  the  deltoid. 

body,  forming  an  angle  of  about  15  degrees  with  that  of  the  arm 
(Fig.  201).  Deviations  from  this  angle  should  be  noted,  as  well  as 
any  lateral  motion  which  is  not  present  in  the  normal  elbow.  Meas- 
urements may  be  made  from  the  tip  of  the  acromion  to  the  tip  of 


Fig.  201. — Outlines  of  upper  extremity 
to  show  A,  normal  carrying  angle;  B, 
cubitus  varsus;  C,  cubitus  valgus.  (Rose 
and^Carless.) 


Fig. 


202. — Supracondyloid  fracture  of 
humerus.     (Gray.) 


the  external  condyle,  from  the  tip  of  the  external  condyle  to  the 
styloid  process  of  the  radius,  and  from  the  tip  of  the  olecranon  to 
the  tip  of  the  styloid  process  of  the  ulna,  as  well  as  between  the  con- 
dyle and  from  either  condyle  to  the  olecranon. 

Supracondyloid  fracture  is  caused  by  a  fall  on  the  hand  when 
the  elbow  is  flexed,  or  by  direct  violence.     The  symptoms  are  pain, 


402 


MANUAL    OF    SURGERY 


swelling,  loss  of  function,  abnormal  mobility,  crepitus,  and  deformity. 
The  lower  fragment  usually  passes  backwards  and  upwards,  thus 
resembling  a  dislocation  of  both  bones  of  the  forearm  backward 
(Fig.  202).  In  dislocation  the  relation  of  the  olecranon  to  the  con- 
dyles is  altered,  in  fracture  the  relations  are  normal;  in  dislocation 
the  forearm  is  shortened,  in  fracture  the  arm  is  shortened.  In 
dislocation  the  lower  end  of  the  humerus*causes  a  smooth  projection 
at  or  below  the  crease  of  the  elbow;  in  fracture  the  upper  fragment 
presents  a  sharp  projection  above  the  crease.     In  dislocation  reduc- 


FiG.  203.- 


-Pastening  figure-of-eight  cra\-a:  over  folded  compression  on.  opposite  side  of 
chest.     Elbow  region  open  to  inspection.      (Scudder.) 


tion  is  difficult  but  permanent,  in  fracture  reduction  is  easy,  but 
difficult  to  maintain;  there  is  no  crepitus  or  abnormal  mobility  in 
dislocation,  and  the  X-ray  will  show  the  bones  out  of  place.  As 
complications  may  be  mentioned  injuries  to  the  brachial  artery  and 
median  nerve. 

The  treatment  is  the  application  of  an  anterior  angular  sphnt 
(Fig.  195),  and  a  posterior  molded  trough  to  the  back  of  the  elbow 
after  effecting  reduction  by  drawing  downwards  and  forwards  on 
the  forearm,  and  pressing  backwards  on  the  upper  fragment.  A 
Stromeyer  splint  is  hinged  and  provided  with  a  screw,  so  that  the 


BONES  403 

angle  may  be  changed  and  thus  some  passive  motion  secured  without 
removing  the  dressings.  The  Jones  position,  i.e.,  acute  flexion  of 
the  elbow,  is  maintained  by  tying  the  wrist  to  the  neck,  or  by  means 
of  a  broad  adhesive  strap  passed  around  the  arm  and  forearm,  which 
are  supported  by  a  figure-of-8  sling  (Fig.  203).  It  is  the  best  form 
of  treatment  for  all  fractures  about  the  elbow,  except  those  of  the 
olecranon  (separates  the  fragments),  T-fractures  of  the  lower  end 
of  the  humerus  (coronoid  wedges  fragments  apart),  fractures  with 
great  swelling  (shuts  ofif  circulation),  and  fractures  involving  the 
groove  of  the  ulnar  nerve  (nerve  slips  into  line  of  fracture).  The 
Jones  position,  indeed  any  kind  of  firm  compression,  should  not  be 
used,  however,  immediately  after  the  accident,  because  of  the  danger 
of  ischemic  myositis  (see  prophylaxis  of  ischemic  myositis,  chap, 
xxxi).  Acute  flexion  reduces  the  fragments,  and  holds  them  in 
place  between  the  coronoid  process  of  the  ulna  and  the  trochlear 
surface  of  the  olecranon  in  front,  and  the  triceps  posteriorly;  it 
preserves  the  carrying  function,  and  gives  a  useful  elbow  even  in  the 
presence  of  ankylosis;  one  must  make  sure  that  the  compression  at 
the  elbow  is  not  too  great  by  feeling  the  radial  pulse  at  the  wrist. 
Some  surgeons  treat  all  fractures  of  the  elbow  in  the  extended 
position,  by  means  of  a  long  splint  or  a  plaster  cast.  It  is  the  best 
position  for  those  cases  in  which  the  Jones  method  is  contraindicated. 
It  preserves  the  carrying  angle,  but  if  ankylosis  occurs  the  limb 
is  in  the  worst  possible  position.  The  right  angle  position  rarely 
holds  the  fragments  in  place,  but  if  ankylosis  occurs  the  arm  is  still 
useful.  Gentle  passive  motion  may  be  commenced  in  three  weeks, 
and  the  splint  removed  at  the  end  of  the  fifth  week.  The  prognosis 
of  fractures  about  the  elbow  should  be  guarded,  and  the  danger 
of  limitation  of  motion  explained  to  the  patient.  In  most  instances, 
however,  a  useful  arm  is  obtained,  although  this  may  not  be  for 
a  number  of  months. 

Intercondyloid,  T-  or  Y-shaped  fracture,  is  a  supracondyloid 
fracture  with  a  fissure  extending  down  between  the  condyles  into  the 
joint.  It  is  caused  by  direct  violence.  There  are  widening  of  the 
elbow',  shortening  of  the  humerus,  and  the  usual  signs  of  fracture. 
The  treatment  is  complete  extension  on  a  straight  splint  for  three 
weeks,  at  which  time  passive  motions  should  be  commenced,  the 
limb  being  placed  on  an  internal  angular  splint  for  two  weeks 
longer. 

The  internal  epicondyle  may  be  broken  by  direct  violence,  forced 
abduction  of  the  extended  elbow,  or  muscular  action.  There  are 
crepitus  and  mobility.    Fracture  of  the  external  epicondyle  gives 


404  MANUAL    OF    SURGERY 

the  same  signs,  and  very  rarely  exists  without  other  injury.     The 
treatment  is  the  Jones  position. 

The  internal  condyle  of  the  humerus  is  broken  by  direct  violence 
the  line  of  fracture  running  into  the  joint.  The  symptoms  are  pain 
abnormal  mobility,  and  crepitus;  the  fragment  with  the  ulna  passes 
upwards,  thus  destroying  the  carrying  function  of  the  arm.  The 
treatment  is  the  Jones  position. 

The  external  condyle  may  be  broken  by  a  fall  on  the  hand,  or  by 
direct  force.  The  line  of  fracture  enters  the  joint  and  includes  the 
capitellum,  or  a  part  of  even  the  trochlear  surface.  The  displace- 
ment is  usually  slight,  but  pain  and  swelling  are  generally  marked. 
Crepitus  and  abnormal  mobility  are  detected  by  grasping  the  condyle 
or  by  rotating  the  radius.  The  treatment  is  the  Jones  position  or  an 
internal  angular  splint. 

Separation  of  the  lower  epiphysis  of  the  humerus  is  not  uncom- 
mon during  childhood,  at  which  time  the  entire  epiphysis,  consisting 
of  several  centers  of  ossification,  is  detached.  The  symptoms  are 
practically  identical  with  those  of  supracondyloid  fracture,  except 
that  the  crepitus  is  softer.  The  treatment  is  the  Jones  position.  The 
possibility  of  interference  with  growth  should  not  be  forgotten. 

The  ulna  may  be  broken  through  the  olecranon,  the  coronoid 
process,  the  shaft,  or  the  styloid  process. 

The  olecranon  is  usually  broken  by  direct  violence,  occasionally 
by  muscular  action.  The  symptoms  are  pain,  swelhng,  abnormal 
mobility,  and  separation  of  the  fragments  owing  to  the  action  of  the 
triceps.  Crepitus  is  not  obtained  unless  the  fragments  are  approxi- 
mated. If  the  periosteum  or  the  tendinous  fibers  of  the  triceps 
covering  the  bone  are  untorn,  separation  may  be  unappreciable 
even  on  flexion  of  the  forearm,  which  ordinarily  widens  to  a  large 
extent  the  breach  between  the  fragments.  The  complications  are 
injury  to  the  ulnar  nerve  and  forward  dislocation  of  the  bones  of  the 
forearm. 

The  treatment  is  the  application  of  a  straight  or  nearly  straight 
anterior  splint,  the  upper  fragment  being  pulled  into  position  by 
means  of  adhesive  strips.  When  union  has  become  firm  enough, 
possibly  at  the  end  of  three  weeks,  the  elbow  should  be  flexed  to  a 
right  angle,  and  placed  on  an  internal  angular  splint  for  one  or  two 
weeks  longer.  The  most  satisfactory  treatment  in  cases  in  which 
there  is  wide  separation  is  the  suturing  of  the  fragments  with  ab- 
sorbable materials  through  an  incision.  The  prognosis  should  be 
guarded.  Fibrous  union  often  occurs,  although  such  may  not 
interfere  with  the  usefulness  of  the  elbow. 


BONES  405 

'JI1C  coronoid  process  is  rarely  broken  alone.  The  fracture  may 
be  associated  with  backward  dislocation  of  the  bones  of  the  forearm 
in  which  case  reduction  is  associated  with  crepitus,  is  easily  made 
and  hard  to  maintain.  The  fragment  may  be  felt  above  its  normal 
position,  where  it  has  been  drawn  by  the  brachialis  anticus.  There 
may  be  inability  to  flex  the  elbow.  The  treatment  is  the  Jones 
position. 

The  shaft  of  the  ulna  is  broken  by  direct  violence.  The  symp- 
toms  are  swelling,  localized  pain,  abnormal  mobility,  and  crepitus. 
There  is  little  or  no  shortening  unless  the  radius  is  broken,  but  the 
lower  forearm  is  thickened  owing  to  the  action  of  the  pronator  quad- 
ratus,  which  draws  the  lower  fragment  into  the  interosseous  space 
while  the  upper  fragment  is  drawn  slightly  forward  by  the  brachialis 
anticus. 

The  treatment  is  an  internal  angular  splint  of  wood  or  light 
moulded  plaster  gutter  which  immobilizes  the  elbow  and  places  the 
forearm  midway  between  pronation  and  supination,  in  which  position 
the  bones  are  farthest  apart  and  the  danger  of  their  union  by  callus 
is  least.  A  posterior  splint,  reaching  from  the  elbow  to  the  wrist 
also  may  be  applied,  while  pieces  of  rubber  tubing  may  be  strapped 
over  the  interosseous  space  on  each  side  of  the  forearm,  in  order  to 
widen  the  interval  between  the  bones.     Union  occurs  in  four  weeks. 

The  Styloid  process  is  broken  by  direct  violence,  and  is  frequently 
detached  in  Colles'  fracture.  The  loose  fragment  may  be  detected 
near  the  wrist. 

The  treatment  is  a  Bond's  splint  (Fig.  195),  with  a  pad  over  the 
styloid  process. 

The  radius  may  be  broken  through  the  head,  neck,  shaft,  or 
lower  extremity. 

The  head  of  the  radius  is  seldom  broken  alone,  but  the  break  may 
complicate  dislocation  of  the  elbow  or  fracture  of  the  external  con- 
dyle. There  are  crepitus  and  immobility  of  the  head  when  the 
forearm  is  rotated.  The  treatment  is  the  Jones  position  or  an  anterior 
angular  splint.  If  the  head  escapes  into  the  joint  as  a  loose  body 
or  unites  wath  deformity,  its  excision  may  be  called  for  to  restore 
the  movements  of  the  elbow. 

The  neck  of  the  radius  is  seldom  broken.  There  are  crepitus 
and  immobility  of  the  head  on  rotation  of  the  forearm,  and  a  promi- 
nence in  front  of  the  elbow,  caused  by  the  lower  fragment,  which  is 
pulled  upwards  and  forwards  by  the  biceps.  The  forearm  is  pro- 
nated  and  voluntary  rotation  lost.  The  treatment  is  the  Jones 
position  or  an  anterior  angular  splint. 


4o6  MANUAL    OF    SURGERY 

The  shaft  of  the  radius  is  usually  broken  by  direct  violence,  and 
and  occasionlly  by  a  fall  on  the  hand.  The  symptoms  are  loss  of  volun- 
tary rotation  in  the  forearm,  localized  pain,  and  immobility  of  the 
head  and  upper  fragment  with  crepitus  upon  passive  rotation  of  the 
forearm.  The  displacement  varies  with  the  site  of  fracture.  When 
the  fracture  is  above  the  insertion  of  the  pronator  radii  teres,  the  upper 
fragment  is  flexed  and  supinated  by  the  biceps  and  supinator  brevis, 
while  the  lower  fragment  is  pulled  towards  the  ulna  and  pronated 
by  the  pronator  quadratus  and  the  pronator  radii  teres,  hence  the 
forearm  is  thickened  below  the  seat  of  fracture.  The  treatment  of 
these  cases  is  full  supination  of  the  forearm  on  an  anterior  angular-' 
splint,  in  order  to  bring  the  lower  fragment  in  contact  with  th^pper, 
which,  owing  to  its  situation  and  small  size,  is  not  under  control. 
Union  takes  place  in  three  or  four  weeks.  When  the  fracture  is 
below  the  insertion  of  the  pronator  radii  teres,  the  upper  fragment 
passes  inwards  and  forwards,  owing  to  the  action  of  the  biceps, 
supinator  brevis,  and  the  pronator  teres,  which  hold  it  also  between 
pronation  and  supination.  The  lower  fragment  passes  into  the 
interosseous  space  and  is  pronated  by  the  pronator  quadratus;  the 
supinator  longus  tilts  the  upper  end  inwards,  but  is  not  suflficiently 
powerful  to  overcome  the  pronation.  The  treatment  is  the  same  as 
that  for  fracture  of  the  shaft  of  the  ulna,  the  arm  being  placed  midway 
between  pronation  and  supination,  because  of  the  danger  of  union 
with  the  ulna  by  callus  formation.  The  dressings  may  be  removed 
in  four  weeks. 

The  lower  end  of  the  radius  is  broken  with  great  frequency. 
A  Colles'  fracture  is  nearly  transverse,  and  is  situated  within  one 
inch  of  the  articular  surface  of  the  radius;  it  may,  however,  be 
oblique  laterally  or  anteroposteriorly.  A  Barton'' s  fracture  involves 
the  posterior  lip  of  the  lower  end  of  the  radius,  the  line  of  fracture 
entering  the  wrist  joint.  Colles'  fracture  is  most  frequent  in  old 
women,  but  may  occur  in  either  sex  at  any  age.  It  is  practically 
always  the  result  of  a  fall  upon  the  palm  of  the  extended  and  pronated 
hand.  Impaction,  fracture  of  the  lower  end  of  the  ulna  or  its  styloid 
process,  and  tearing  of  the  internal  lateral  ligament  with  subsequent 
dislocation  of  the  lower  end  of  the  ulna,  are  not  unusual  complications. 
As  a  rule  a  strip  of  periosteum  on  the  posterior  surface  remains 
untorn. 

The  symptoms  are  swelling,  localized  pain,  and  loss  of  function. 
Abnormal  mobihty  and  crepitus  are  frequently  absent.  The  lower 
fragment  passes  upward  and  backward  as  the  result  of  the  direction 
of  the  violence,  producing  the  silver  fork  deformity  fFig.   204) ;  as 


BONES  407 

most  of  the  force  is  transmitted  through  the  ball  of  the  thumb, 
the  displacement  is  also  outward,  thus  causing  abduction  of  the 
hand  and  prominence  of  the  styloid  process  of  the  ulna,  which  is 
found  on  a  level  with  or  lower  than  the  radial  styloid,  which  is  nor- 
mally the  lower  point.  The  lower  fragment  is  also  tilted,  because  the 
brunt  of  the  force  is  received  on  the  posterior  lip  of  the  articular  surf- 
ace, which  looks  downward  and  backward  instead  of  downward 
and  forward.  The  hand  is  pronated,  and  separated  from  the  fore- 
arm by  a  deep  depression  on  the  flexor  surface,  caused  by  the  back- 
ward displacement  of  the  lower  fragment  and  the  prominence  of  the 
lower  end  of  the  upper  fragment.  The  distance  between  the  styloid 
processes  is  lengthened  and  that  between  the  external  condyle  and  the 
radial  styloid  is  shortened.  In  rare  instances,  as  the  result  of  falls 
on  the  back  of  the  hand,  the  lower  fragment  is  displaced  forward 
instead  of  backward  (Fig.  205). 

The  Treatment." — Reduction  is  accomplished  by  hyperextension, 
to  free  the  fragments  and  relax  the  untorn  dorsal  periosteum,  and 


Fig.  204. — CoUes'  fracture  showing  Fig.  205. — Fracture  of  lower  end 

silver  fork  deformity.  of  radius  with  forward  displacement, 

showing  gardener's  spade  deformity. 

direct  pressure  on  the  lower  fragment,  to  force  it  in  place,  as  the 
wrist  is  flexed  and  the  hand  adducted  (toward  the  ulna).  These 
movements  may  be  quickly  performed  by  locking  the  fingers  be- 
neath the  upper  fragment  and  using  the  thumbs  to  control  the 
lower  fragment.  Great  force  is  often  required  to  reduce  this  fracture, 
and  unless  such  can  be  effected  quickly  and  at  the  first  attempt,  the 
patient  should  be  anesthetized.  Reduction  is  best  maintained  by 
means  of  the  Bond  splint  (Fig.  195),  fully  padded  beneath  the  hollow 
of  the  wrist,  so  that  when  placed  on  the  splint  the  hand  will  be  semi- 
flexed and  adducted.  The  fingers  are  not  bandaged.  The  dressings 
are  changed  every  two  or  three  days,  and  while  the  fragments  are 
held  firmly  in  place  with  one  hand,  the  fingers  and  wrist  are  gently 
moved,  at  even  the  second  dressing.  The  splint  may  be  permanently 
removed  in  three  weeks.  The  Levis  sphnt  (Fig.  206)  acts  on  the 
same  principle  as  the  Bond  splint.  A  moulded  plaster  gutter  splint 
can  be  shaped  as  the  Levis  splint.  Roberts  uses  a  straight  pos- 
terior   splint.     When  the  fragments  are  perfectly  reduced  and  im- 


4o8 


MANUAL    OF    SURGERY 


pacted  some  surgeons  do  not  use  splints  Ijut  have  the  wrist  and 
forearm  carried  in  a  triangular  muslin  sling  supported  from  the 
neck.  In  simple  Colles'  fracture  in  the  young  and  healthy  the 
prognosis  is  good  both  regarding  contour  and  function,  but  if  there 
is  comminution  or  much  impaction,  some  deformity  will  result  no 
matter  what  treatment  is  employed,  while  in  cases  with  associated 
joint  injury,  or  in  the  old  and  rheumatic,  limitation  of  motion 
frequently  follows  the  most  careful  treatment.     If   the  bone  has 


Fig.   206. — The  Levis  splint. 

united   in   deformity  and    there   is   much  impairment  of  function, 
reduction  after  osteotomy  should  be  considered. 

Separation  of  the  lower  epiphysis  of  the  radius  may  occur  before 
the  twentieth  year,  the  epiphysis  passing  backward.  It  differs 
from  Colles'  fracture  in  that  the  dorsal  swelling  is  less,  the  flexor  or 
diaphyseal  projection  is  greater,  lateral  deformity  is  rarely  present, 
and  crepitus  is  softer  and  more  easily  obtained.     The  treatment  is 


Fig.  207. — Jones'  cock-up  splint. 

that  of  Colles'  fracture.     The  danger  of  interference  with  the  growth 
of  the  radius  should  be  borne  in  mind. 

Fracture  of  both  bones  of  the  forearm  (Fig.  207a)  may  be  due  to 
direct  or  indirect  violence;  it  is  most  frequent  in  the  middle  and 
lower  thirds.  As  a  rule  the  upper  fragments  are  approximated  and 
pronated,  w^hile  the  ends  of  the  low^er  fragments  also  approach  each 
other  and  may  be  found  in  front  of  or  behind  the  upper  fragments, 
hence  the  forearm  is  narrowed  from  side  to  side  and  thickened 


BONES  409 

anteroposteriorly.  There  are  also  shortening,  crepitus,  preternatu- 
ral mobility,  pain,  swelling,  and  loss  of  active  rotation. 

The  treatment  of  fractures  below  the  insertion  of  the  pronator  teres 
is  the  same  as  that  for  fracture  of  the  shaft  of  the  ulna,  .the  forearm 
being  placed  midway  between  pronation  and  supination,  and  the 
interosseous  space  preserved  by  means  of  pads.  In  fractures  above 
this  point  the  forearm  should  be  put  on  an  anterior  angular  splint, 
in  full  supination.  If  there  is  a  persistent  tendency  to  ulnar  bowing 
of  the  forearm,  i.e.,  convex  toward  the  ulnar  side,  the  elbow  may  be 
extended  and  a  long  straight  splint  or  a  plaster  cast  appHed.  Union 
is  usually  firm  in  four  weeks. 

The  carpal  bones  are  seldom  broken,  except  in  crushes  in  which 
the  fracture  is  compound  and  associated  with  injuries  to  neighboring 
bones.  Until  the  advent  of  the 
X-ray  simple  fractures  of  the 
carpal  bones  were  usually 
treated  as  sprain,  weak  wrist, 
rheumatism,  etc.  Although 
any  of  the  carpal  bones  may  be 
involved  in  a  simple  fracture, 
the  scaphoid  is  the  one  most 
frequently  broken,  often  being 
associated  with  anterior  disloca- 
tion of  the  semilunar  bone;  the 
proximal  fragment  passes  for- 
ward   with    the    semilunar. 

There  is  a    ''history  of  a  fall  on     ^i^-  207a.— Fracture  of  both  bones  of    the 

forearm. 

the    extended   hand;    localized 

swelling  of  the  radial  half  of  the  wrist  joint;  acute  tenderness  in  the 
anatomical  snuff-box  when  the  hand  is  adducted;  limitation  of  exten- 
sion by  muscular  spasm,  the  overcoming  of  which  by  force  causes 
unbearable  pain.  The  possibility  of  the  existence  of  a  bipartite 
scaphoid  should  be  considered  in  interpreting  X-rays  of  simple  frac- 
ture of  the  scaphoid"  (Codman  and  Chase).  Crepitus  may  be  ob- 
tained in  some  instances  of  simple  fracture  of  the  carpus.  The 
treatment  in  compound  fractures  is  disinfection  and  the  application 
of  a  straight  palmar  splint,  or  possibly  resection  of  bone  or  amputa- 
tion. In  simple  fractures  deformity,  if  present,  should  be  reduced 
by  traction  and  direct  pressure,  and  the  wrist  immobilized  for  three 
or  four  weeks  by  a  palmar  or  dorsal  splint.  If  pain  and  stiffness 
persist  after  fracture  of  the  scaphoid,  excision  of  the  bone  through  a 
dorsal  incision  may  give  rehef. 


4IO  MANUAL    OF    SURGERY 

The  metacarpal  bones  may  be  broken  by  direct  or  indirect  force. 
Bennett's  fracture  is  a  fracture  of  the  proximal  end  of  the  metacarpal 
bone  of  the  thumb  involving  the  articular  surface.  The  symptoms 
are  pain,  swelling,  crepitus,  abnormal  mobility,  posterior  angular 
deformity,  and  flattening  of  the  knuckle  of  the  affected  bone.  The 
treatment  is  reduction  by  traction  and  direct  pressure,  and  the  appli- 
cation of  a  straight  palmar  splint,  well  padded  to  fill  up  the  hollow 
of  the  palm.  It  may  be  necessary  to  apply  a  dorsal  pad  over  the 
deformity,  and  permanent  extension  to  the  finger  by  adhesive  strips 
passing  to  the  end  of  the  spHnt.  The  dressing  should  be  worn  for 
three  weeks. 

The  phalanges  are  generally  broken  by  direct  violence,  which 
frequently  renders  the  fracture  compound.  The  symptoms  are 
pain,  swelling,  mobility,  crepitus,  loss  of  function,  and  little  or  no 
deformity.  The  treatment  is  the  application  of  a  molded  splint  of 
cardboard  or  a  straight  wooden  splint,  which  in  fracture  of  the 
proximal  phalanx  should  extend  into  the  palm.  In  some  cases  it 
may  be  desirable  to  bandage  adjacent  fingers  together  on  a  spHnt, 
so  as  to  provide  lateral  support.  The  splint  may  be  discarded  in 
three  weeks. 

Fractures  of  the  pelvis  are  due  to  direct  violence,  as  in  a  crushing 
accident,  or  to  violence  transmitted  through  the  vertebral  column  or 
the  femora. 

Fractures  of  the  false  pelvis,  i.e.,  of  the  spines,  crests,  or  ala  of  the 
ilia,  are  not  in  themselves  serious,  as  displacement  is  slight.  The 
complications  may,  however,  be  highly  dangerous;  they  are  more 
often  associated  with  comminuted  fractures,  and  involve  the  abdo- 
minal viscera.  The  symptoms  are  pain,  swelling,  ecchymosis, 
mobility,  crepitus,  and  but  little  or  no  deformity.  The  treatment 
is  rest  in  bed,  with  the  shoulders  elevated  and  the  thighs  flexed 
to  relax  the  muscles,  and  the  appUcation  of  a  broad  flannel  binder 
around  the  pelvis.  Rupture  of  the  bowel  will  require  laparotomy. 
Union  occurs  in  four  or  five  weeks. 

Fractures  of  the  true  pelvis  are  always  serious  because  of  the 
danger  of  complicalions,  such  as  rupture  of  the  bladder,  urethra, 
or  injury  to  the  bowel,  uterus,  or  vagina.  The  fracture  usually 
extends  into  the  obturator  foramen,  either  through  the  horizontal 
ramus  of  the  pubes  or  the  ascending  ramus  of  the  ischium. 
It  may  be  associated  with  fracture  through  the  opposite  sacroiliac 
joint,  or  there-  may  be  many  lines  of  fracture  in  different 
parts  of  the  pelvic  ring.  The  symptoms  are  shock,  pelvic  pain, 
especially  on    coughing,    straining,  or    moving    the  legs,   swelling, 


BONES  411 

ecchymosis,  inability  to  sit  or  stand,  and  rarely  deformity. 
Mobility  and  crepitus  may  be  obtained  by  grasping  the  pelvis  on 
each  side  and  making  alternate  pressure  or  by  inserting  the  finger 
into  the  vagina  or  rectum  while  one  side  of  the  pelvis  is  moved  on 
the  other.  It  should  be  remembered  that  rough  manipulations  may 
drive  sharp  fragments  into  the  viscera.  Bleeding  from  the  urethra, 
vagina,  or  rectum  should  be  most  carefully  investigated. 

The  treatment  is  first  to  react  the  patient  from  shock,  and  care- 
fully exclude  visceral  injuries,  which  if  present,  are  to  be  repaired 
as  described  under  their  respective  headings.  The  fragments  are 
reduced  by  external  manipulation,  or  by  combined  external  and 
internal  manipulation,  and  the  patient  placed  on  a  firm  bed  or  a  Brad- 
ford frame,  with  a  broad  binder  encircling  the  pelvis.  In  some  frac- 
tures of  the  pubic  bone  wiring  may  be  indicated.  Union  occurs  in 
about  six  weeks,  but  the  patient  should  be  kept  in  bed  several  weeks 
longer,  then  allowed  to  get  about  with  a  firm  binder  and  crutches. 

Fracture  of  the  acetabulum  may  complicate  dorsal  dislocation  of 
the  femur,  the  posterior  lip  giving  way;  or  the  head  of  the  femur,  in 
falls  on  the  trochanter,  may  fissure  the  acetabulum,  or  even  perforate 
it  and  enter  the  pelvis,  in  which  case  the  viscera  may  be  damaged. 
In  fracture  of  the  posterior  lip  the  head  of  the  femur  is  easily  reduced, 
with  crepitus,  but  the  deformity  shows  a  strong  tendency  to  recur. 
When  the  head  of  the  bone  has  been  driven  into  the  pelvic  cavity 
a  fracture  of  the  neck  of  the  femur  may  be  simulated,  but  there  is 
less  mobihty,  and  greater  flattening  of  the  trochanter,  and  the  head 
of  the  bone  may  be  palpated  through  the  rectum.  The  treatment 
is  reduction  by  traction  and  external  manipulation,  and  the  applica- 
tion of  permanent  extension  as  in  fracture  of  the  neck  of  the 
femur. 

The  sacrum  is  broken  by  direct  violence.  Comminution  may  be 
present,  and  injury  to  the  sacral  plexus  is  frequent,  perhaps  causing 
paralysis  of  the  bladder  and  rectum.  In  a  transverse  fracture  the 
lower  fragment  generally  passes  forwards,  and  may  press  upon  or 
tear  the  rectum.  Mobility  and  crepitus  may  be  detected  by  placing 
one  finger  in  the  rectum  and  making  external  pressure.  The  treatment 
is  reduction  by  pressure  within  the  rectum,  and  the  application  of  a 
pelvic  binder,  with  a  large  pad  over  the  upper  part  of  the  sacrum,  so 
that  external  pressure  will  not  be  made  on  the  lower  fragment. 
Laceration  of  the  rectum  may  require  suture.  In  the  presence  of 
injury  to  the  sacral  plexus  elevation  and  fixation  of  the  depressed 
fragments  through  an  external  incision  will  be  indicated.  In  these 
cases  great  care  must  be  taken  lest  bed  sores  develop  or  lest  infection 


412  MANUAL    OF    SURGERY 

of  the  bladder  from  catheterization  result.  The  bone  unites  in  four 
or  five  weeks. 

The  coccyx  is  normally  mobile,  but  it  may  be  broken  by  a  fall  or  a 
kick.  The  symptoms  are  pain,  more  marked  on  walking,  coughing, 
and  defecation;  mobility;  crepitus;  and  perhaps  turning  in  of  the 
fragment,  appreciable  on  rectal  examination.  The  treatment  is  rest 
in  bed  for  four  weeks;  the  bone  cannot  be  splinted.  Coccygodynia 
is  a  severe  form  of  neuralgia  following  injuries  to  the  coccyx.  It  may 
be  due  to  non-union  or  vicious  union,  but  occasionally  occurs  in 
cases  in  which  there  has  been  no  fracture.  The  pain  is  similar  to 
that  occurring  in  fracture,  and  may  be  so  harassing  as  to  induce 
neurasthenia.  If  relief  cannot  be  obtained  by  medical  treatment,  the 
coccyx  may  be  excised  through  a  straight  incision  in  the  middle  line, 
care  being  taken  not  to  injure  the  rectum. 

Fractures  of  the  upper  extremity  of  the  femur  include  intra-and 
extracapsular  fractures  of  the  neck,  fractures  of  the  great  trochanter, 
fractures  of  the  lesser  trochanter,  and  separation  of  the  upper 
epiphysis. 

Intracapsular  fracture  of  the  neck  of  the  femur  is  most  frequent 
in  elderly  women,  although  it  may  occur  in  either  sex  or  at  any  age. 
In  old  age  the  neck  of  the  bone  is  more  horizontal,  and  the  bony 
tissue  is  atrophied  and  infiltrated  with  fat,  hence  slight  indirect 
force,  such  as  catching  the  toe  in  a  piece  of  carpet,  or  suddenly 
throwing  the  weight  of  the  body  upon  the  lower  extremity,  is  a 
frequent  cause  of  this  accident  in  the  elderly.  Impaction  is  unusual, 
and  although  some  of  the  reflected  fibers  of  the  capsule  or  a  portion 
of  the  periosteum  may  remain  untorn,  the  head  of  the  bone,  as  a 
rule,  is  entirely  separated  except  for  its  attachment  to  the  acetabulum 
by  the  ligamentum  teres,  through  which  it  receives  sufficient  blood 
to  maintain  its  vitahty.  Hence  non-union  or  at  best  fibrous  union  is 
a  frequent  occurrence,  particularly  in  the  aged  and  debilitated. 

The  symptoms  are  pain,  little  or  no  swelhng  and  ecchymosis 
(unless  the  patient  has  fallen  on  the  trochanter  after  the  neck  has 
broken),  loss  of  function,  helpless  eversion  (the  limb  lying  on  its  outer 
side  as  the  result  of  gravity  and  the  action  of  the  external  rotators; 
inversion  is  possible  but  very  rare),  crepitus  if  there  is  no  impaction, 
lessened  arc  of  rotation  of  the  great  trochanter  (the  radius  extending 
to  the  line  of  fracture  instead  of  to  the  acetabulum),  inward  dis- 
placement of  the  great  trochanter  (found  by  measuring  the  distance 
between  the  median  line  of  the  body  and  the  outer  surface  of  each 
trochanter) ,  and  slight  shortening  (one-half  to  one  inch) ,  which  in  a 
few  days  may  increase  to  two  or  more  inches,  owing  to   muscular 


BONES 


413 


spasm,  unlocking  of  impacted  fragments,  or  laceration  of  untorn 
periosteal  or  fibrous  tissue.  Shortening  may  be  determined  by  one 
of  the  following  methods:  i.  The  limbs  may  be  measured  from  the 
anterior  superior  spine  of  the  iHum  to  the  internal  malleolus.  The 
patient  should  be  perfectly  Hat  and  straight  upon  a  firm  bed,  so  that 
a  straight  line  drawn  from  the  episternal  notch  to  midway  between 
the  internal  malleoli  will  intersect  the  umbilicus,  the  symphysis 
pubis,  and  the  midpoint  between  the  knees,  and  a  line  passing  through 
each  anterior  superior  spine  of  the  ihum  will  be  perpendicular 
to  the  axis  of  the  body.  The  tip  of  the  anterior  superior  spine  and 
the  tip  of  the  internal  malleolus  are  marked  with  a  pencil,  and  in 
measuring  the  skin  is  not  pressed  upon  lest  it  become  displaced.  A 
difference  of  a  quater  of  an  inch  is  not  unusual  normally,  and  excep- 
tionally it  may  be  even  much  greater,  so  that  in  case  of  doubt  the 
tibiae  may  be  measured  to  determine 
the  presence  or  absence  of  symmetry. 
Normally  a  straight  line  from  the 
anterior  superior  spine  to  the  tip  of  the 
malleolus  passes  through  the  center  of 
the  patella.  2.  Nelatons^s  line  is  one 
passing  from  the  anterior  superior 
spine  of  the  ilium  to  the  most  prominent 
part  of  the  tuberosity  of  the  ischium. 
Normally  when  the  lower  limb  lies  in 
the  axis  of  the  body,  midway  between       „  .^^    ^t-,       .    i- 

-^  '  .  Pig.   208. — AD,    Nelaton  s    line; 

internal  and  external  rotation,  the  top  abc,  Bryant's  triangle;  BC,  test- 

Of  the    trochanter   touches   the   middle    Ime^f^rJ^racture  or  shortening  of  neck 

of  this  line;  in  fracture  it  passes  above 

the  line.  3.  Bryant's  triangle  (Fig.  208)  consists  of  a  line  from  the 
anterior  superior  spine  to  the  top  of  the  trochanter,  and  another  from 
the  anterior  superior  spine,  drawn  downward  perpendicularly  to 
the  axis  of  the  body,  to  meet  at  a  right  angle  one  drawn  upward 
from  the  trochanter.  Shortening  of  the  last  line  as  compared  with 
the  opposite  side  of  the  body  shpws  the  amount  of  shortening  of  the 
limb.  4.  Relaxation  of  the  fascia  lata,  as  determined  by  pressure 
above  the  great  trochanter,  also  indicates  shortening  of  the  femur. 
In  children,  in  whom  this  fracture  is  more  common  than  was  once 
supposed,  there  is  usually  the  history  of  a  severe  fall  rather  than  a 
trivial  twist,  and  the  fracture  is  often  impacted  or  of  the  green-stick 
variety,  so  that  the  disability  may  be  slight  and  the  bony  injury 
readily  overlooked.  Later,  however,  owing  to  the  lack  of  proper 
treatment,  the  neck  bends  (coxa  vara)   and  a  permanent  limp  is 


414  MANUAL    OF    SURGERY 

produced,  which,  with  the  slight  pain  and  limitation  of  motion,  may 
be  mistaken  for  hip  disease.  The  symptoms  of  fracture  of  the  femoral 
neck  in  children  are  slight  eversion,  limitation  of  abduction,  and 
shortening;  crepitus  and  abnormal  mobility  are  usually  absent. 
The  diagnosis  is  confirmed  by  the  X-ray.  The  complications  in  the 
old  are  mainly  due  to  confinement  to  bed,  e.g.,  bed  sores  and  hypo- 
static pneumonia.  Non-union,  fibrous  union,  atrophy  and  absorp- 
tion of  the  head,  in  the  old,  and  coxa  vara  in  the  young  are  among 
the  sequelae. 

The  treatment  is  seldom  satisfactory.  Aged  patients  rarely 
tolerate  confinement  to  bed  for  the  necessary  length  of  time  to 
obtain  union,  and,  should  there  be  evidences  of  impairment  of  the 
general  health,  the  patient  should  be  allowed  to  sit  up  and  leave  the 
bed  at  the  earliest  possible  date,  making  no  attempt  to  fix  the  fracture. 
The  usual  method  of  treatment  is  by  Buck's  extension  apparatus, 
with  sand  bags  for  lateral  support.  The  patient  is  placed  on  a 
firm  mattress,  which  is  kept  flat  by  boards  placed  between  it  and  the 
frame  of  the  bed.  Impaction  should  never  be  broken  up,  except 
possibly  in  the  young,  hence  one  should  never  try  to  obtain  crepitus 
and  mobihty,  and  should  be  careful  in  moving  the  patient.  A  hairy 
leg  should  be  shaved,  and  the  foot  and  ankle  bandaged.  A  strip  of 
adhesive  plaster,  about  two  inches  wide,  and  long  enough  to  run 
from  the  seat  of  the  fracture  to  below  the  sole  of  the  foot  and  back 
again,  is  prepared  by  fastening  to  its  center  a  piece  of  board,  with  a 
hole  in  the  middle,  and  a  little  longer  than  the  width  of  the  foot 
(Fig.  195).  The  plaster  is  apphed  to  the  sides  of  the  lower  extremity 
up  to  the  seat  of  the  fracture,  and  the  bandage  continued  over  the 
plaster.  A  piece  of  rope  is  knotted,  then  passed  through  the  open- 
ing in  the  board  and  over  a  pulley  at  the  end  of  the  bed  (Fig.  195) 
To  this  should  be  attached  a  weight  of  five  pounds  (  a  brick  weighs 
about  five  pounds),  unless  there  is  great  shortening  and  no  impaction, 
in  which  case  the  weight  should  be  sufficient  to  restore  the  normal 
length  of  the  hmb.  The  foot  of  the  bed  is  raised  five  or  six  inches 
to  obtain  counterextension  by  the  weight  of  the  body.  The  limb  is 
slightly  abducted,  rotated  inward  to  correspond  with  the  other  limb, 
and  supported  from  the  sides  by  sand  bags,  the  outer  reaching  from 
the  chest  to  below  the  foot,  and  the  inner  from  the  perineum  to 
below  the  foot.  A  pad  is  placed  beneath  the  popliteal  space,  and  a 
bird's  nest  of  cotton  beneath  the  heel  to  relieve  pressure.  A  cradle 
(Fig.  209)  may  be  placed  over  the  leg  to  support  the  bed  clothing. 
The  patient  should  be  kept  in  bed  six  or  eight  weeks,  and  should 
bear  very  little  weight  on  the  extremity  for  three  months  from  the 


BONES  415 

time  of  injury,  indeed  crutches,  or  at  least  a  cane,  are  usually  neces- 
sary for  many  months,  if  not  permanently. 

Senn  encases  the  pelvis  and  the  lower  extremity  in  plaster-of- 
Paris  leaving  an  opening  over  the  great  trochanter,  upon  which 
lateral  pressure  is  made  by  means  of  a  screw  apparatus  which  has 
been  incorporated  in  the  plaster. 

Tlie  Thomas  hip  splint  (Fig.  247)  immobilizes  the  fracture  by 
fixing  the  pelvis  and  the  thigh,  and  allows  the  patient  to  be  moved 
about  without  danger  of  disturbing  the  fragments.  The  sphnt 
is  of  iron,  with  bands  encircling  the  chest,  thigh,  and  calf.  The 
method  is  an  excellent  one  if  the  splint  is  at  hand  and  the  practi- 
tioner possesses  the  requisite  skill  to  adjust  it.  Whitman  advises 
the  breaking  up  of  impaction  under  anesthesia,  and  fixation  of  the 
limb  at  the  limit  of  normal  abduction,  by  means  of  a  plastcr-of-Paris 
spica.  He  beHeves  this  treatment  is  applicable  to  all  cases.  If 
non-union  occurs  in  young  and  healthy  adults,  the  fragments  may 
be  fixed  by  driving  a  nail,  screw,  or  bone  peg  through  the  trochanter 
into  the  head  of  the  femur,  after  exposing  these 
parts  by  incision.  The  prognosis  is  bad  in  the 
old.  Death  may  occur  from  shock,  exhaustion, 
or  from  pneumonia  or  other  visceral  disease. 
Complete  recovery  is  rare,  there  usually  being 
pain,  weakness,  and  limping.  In  cases  of  non- 
union not  suitable  for  operation,  some  relief  may  Pi^.  209.— Cradle. 
be  obtained  by  means  of  a  hip  support. 

The  so-called  extracapsular  fracture  of  the  neck  of  the  femur  is  in 
reality  only  extracapsular  posteriorally,  the  line  of  fracture  anterior- 
ally  being  covered  by  the  capsule.  The  cause  is  direct  violence  to  the 
trochanter  as  a  fall  on  the  hip,  hence  impaction  is  common;  if  the  vio- 
lence be  greater  the  trochanter  is  involved,  sometimes  with  extensive 
comminution.  The  symptoms  are  much  the  same  as  those  of  intra- 
capsular fracture,  except  that  in  the  former  there  is  greater  pain 
swelling,  ecchymosis,  and  primary  shortening,  and  later  more 
thickening  as  the  result  of  callus  formation.  The  treatment  is  the  same 
as  that  of  intracapsular  fracture.  The  prognosis  is  very  much  more 
favorable  than  in  intracapsular  fracture;  bony  union  is  the  rule, 
although  some  shortening  is  inevitable. 

Fracture  of  the  great  trochanter  is  the  result  of  direct  violence, 
the  line  of  fracture  running  through  the  base  of  the  trochanter  to  the 
lower  part  of  the  neck  of  the  bone.  The  symptoms  are  very  simi- 
lar to  those  of  extracapsular  fracture.  The  lower  fragment  with  the 
lesser  trochanter  passes  upward  and  backward   toward  the  sciatic 


4l6  MAXUAL    OF    SURGERY 

notch,  and  may  be  palpated  posteriorly.     The  treatment  is  that  of 
extracapsular  fracture. 

Separation  of  the  great  trochanter  without  fracture  of  the  shaft 
is  very  rare,  and  in  youth  is  due  to  separation  of  the  epiphysis  of  the 
great  trochanter.  The  cause  is  direct  violence.  The  symptoms  are 
mobility  of  the  trochanter  and  crepitus.  The  length  of  the  Umb  and 
the  motions  of  the  hip  joint  are  not  affected.  The  treatment,  if 
there  is  little  or  no  displacement,  is  that  of  fracture  of  the  neck. 
If  the  fragment  is  pulled  upward  and  backward  away  from  the 
shaft,  the  thigh  may  be  flexed  and  rotated  externally,  while  adhesive 
straps  are  applied  to  pull  the  trochanter  downward.  Far  better 
in  such  a  case  is  fixation  by  screws,  or  bone  pegs,  through  an  open 
incision. 

Fracture  of  the  lesser  trochanter  may  occur  in  the  young.  Eight 
cases  have  been  reported,  one  from  direct  violence,  and  the  rest 
from  avulsion  the  result  of  contraction  of  the  psoas  when  the  thighs 
were  spread  apart.  The  symptoms  are  external  rotation  of  the  thigh, 
pain  and  tenderness  two  or  three  inches  below  the  groin  in  Scarpa's 
triangle,  and  ecchymosis  along  the  inner  surface  of  the  thigh. 
Crepitus  and  abnormal  mobility  cannot  be  ehcited,  owing  to  the 
depth  of  the  injury,  and  there  is  no  shortening  or  deformity.  The 
patient  is  able  to  raise  the  heel  from  the  bed  when  lying  down  (as 
this  is  done  by  the  rectus  and  the  muscles  on  the  anterior  surface 
of  the  thigh),  but  not  when  sitting,  as  the  rectus  is  then  relaxed  and 
the  psoas  must  do  the  lifting  (Ludlow's  sign).  This  sign  differenti- 
ates this  injury  from  a  fracture  of  the  femoral  neck,  in  which  the  leg 
cannot  be  raised  when  the  patient  is  lying  down.  The  diagnosis 
is  confirmed  by  the  X-ray.  The  treatment  is  fixation  of  the  thigh  in 
flexion  and  internal  rotation,  in  order  to  relax  the  psoas. 

Separation  of  the  epiphysis  of  the  head  of  the  femur  is  uncommon, 
but  may  occur  in  early  life.  Growth  of  the  limb  may  be  impaired,  or 
coxa  vara  may  result.  The  symptoms  are  those  of  intracapsular 
fracture,  although  less  marked  and  accompanied  by  soft  crepitus. 
The  treatment  is  that  of  intracapsular  fracture. 

The  diagnosis  of  injuries  about  the  hip  should  be  made  only 
after  a  comparative  examination  of  both  sides.  The  tape  measure 
and  the  X-ray  are  the  greatest  aids.  In  contusion  or  sprain  men- 
suration will  reveal  neither  shortening  of  the  limb  nor  flattening  of 
the  hip,  although  individual  variations  from  the  normal  should  be 
remembered.  It  should  be  recalled,  however,  that  shortening  may 
som^etimes  occur  late  after  contusion,  owing  to  atrophy  and  absorp- 
tion of  the  head  of  the  bone.     Crepitus  with  shortening  may  be 


BONES  417 

found  in  chronic  osteoarthritis  of  the  hi]),  hut  they  antedate  the 
accident  and  are  probably  associated  with  similiar  changes  in  other 
joints;  moreover,  the  trochanter  is  more  often  prominent  than 
flattened,  and  there  is  no  relaxation  of  the  fascia  lata.  An  impacted 
fracture  gives  no  crepitus,  and  presents  a  large  arc  of  rotation  of 
the  great  trochanter,  but  is  accompanied  by  shortening  which  is 
not  affected  by  extension.  Dislocation  occurs  in  young  adults, 
never  as  the  result  of  direct  violence,  but  always  from  force  applied 
to  the  knee,  foot,  or  back  when  the  thigh  is  flexed;  there  is  no 
crepitus  and  the  head  of  the  bone  may  be  felt  in  its  new  position. 
In  dorsal  dislocation  the  limb  is  adducted  and  inverted,  while  in 
forward  dislocation  there  is  abduction  and  outward  rotation;  in  the 
obturator  variety  of  the  latter  there  is  lengthening  of  the  hmb. 
Fractures  of  the  shaft  of  the  femur  are  most  frequent  in  the  middle 
third.  Fracture  of  the  upper  third  is  uncommon  and  usually  due  to 
indirect  violence.  Fracture  of  the  lower  third  is  usually  due  to 
direct  violence.     The  middle  of  the  bone  may  be  broken  in  either 


Fig.   210. — Fracture  of  the  shaft  of  the  femur. 

way  and  occasionally  from  muscular  action.  The  fractures  are 
generally  oblique  and  displacement  is  the  rule,  hence  injury  to  the 
soft  parts  is  of  frequent  occurrence,  and  occasionally  the  vessels  or 
nerves  are  lacerated. 

The  symptoms  are  pain,  swelling,  muscular  spasm,  abnormal 
mobihty,  crepitus,  deformity,  and  shortening.  In  the  upper  third 
the  upper  fragment  is  pulled  forward  by  the  iliopsoas,  and  drawn 
outward  and  rotated  externally  by  the  external  rotators;  the  lower 
fragment  is  pulled  upward  by  the  flexors  and  extensors  of  the  leg, 
inward  by  the  adductor  muscles,  and  rolled  outward  by  the  weight 
of  the  limb.  In  the  middle  third  the  displacement  is  much  the  same, 
although  here  any  variety  of  deformity  may  be  produced,  according 
to  the  form  and  the  direction  of  the  violence.  In  the  lower  third 
the  gastrocnemius  draws  the  lower  fragment  backward,  and  thus 
endangers  the  popliteal  vessels. 

The  treatment  of  fractures  of  the  upper  third  is  flexion  of  the  thigh, 
to  place  the  extremity  in  the  position  of  muscular  relaxation,  and 

27 


4i8 


MANUAL    OF    SURGERY 


traction  to  reduce  the  deformity,  this  position  is  best  obtained 
in  the  suspension  and  extension  dressing  of  Blake  (Fig.  211) 
with  extension  in  the  axis  of  the  thigh.  The  principle  of  the 
double-inclined  plane  is  utilized  also  in  the  Mclntyre  splint,  the 
Nathan  R.  Smith  anterior  spHnt,  and  the  Hodgen  splint.  The 
Nathan  R.  Smith  sphnt  is  made  of  strong  wire,  bent  to  the  de- 
sired shape;  it  is  applied  to  the  anterior  surface  of  the  limb  and 
suspended  by  cord  and  pulley.  The  Hodgen  sphnt  consists  of  two 
long  pieces  of  wire  joined  at  thedistal  extremity  and  reinforced  at  the 
middle  and  upper  end  by  cross  pieces.  The  limb  rests  in  a  trough 
of  flannel  or  towels  attached  to  the  frame.     A  Buck's  extension  is 


Fig.   211.^ — Blake's  suspension   and  extension  applied  to  the  lower  extremity  with   a 

Hodger  splint. 

applied  and  attached  to  the  foot  piece,  and  further  extension  made 
by  suspending  the  limb  by  cords,  passing  obliquely  upward  to 
a  vertical  post  at  the  foot  of  the  bed.  The  apphcation  of  a 
Buck's  extension  to  the  thigh  below  the  fracture  or  by  skeletal  trac- 
tion to  the  Icwer  fragments  are  recent  modifications  of  the  original 
Hodgen  method  and  supplant  the  indirect  traction  upon  the  leg.  All 
forms  of  treatment,  however,  are  unsatisfactory,  and  if  the  displace- 
ment is  marked  and  the  patient  young  and  healthy,  operative 
fixation  should  be  considered.  In  fractures  of  the  middle  third  a 
Buck's  extension  is  apphed  up  to  the  seat  of  fracture,  and  enough 
weight  attached  to  the  cord  to  overcome  the  shortening.  Lateral 
displacement  is  corrected  by  sand  bags,  lateral  splints,  or  a  molded 


BONES  419 

splint.  In  the  lower  third  horizontal  traction  may  ])c  tried,  as  in  the 
middle  third,  but  if  there  is  a  marked  tendency  to  displacement  of 
the  lower  fragment  backward,  the  double-inclined  plane  should  be 
used.  Tenotomy  of  the  tendo  Achillis  is  useful  in  some  cases. 
Bardenheuer  treats  fractures  in  all  parts  of  the  femur,  and  indeed 
fractures  in  other  bones  of  the  extremities,  by  lateral  as  well  as  longi- 


FiG.   212. — Calipers  for  skeletal  traction. 

tudinal  extension  (Fig.  213).  In  order  to  make  powerful  traction 
Steinmann  advises  "nail  extension."  As  the  Steinmann  procedure 
is  attended  by  some  danger  of  infection,  it  has  been  replaced  by 
the  skeletal  calipers  or  ice  tongs  of  Ransohoff  (Fig.  212).  Fractures 
of  the  thigh  unite  in  six  or  eight  weeks. 

The  suspension  and  extension  dressing  of  Blake  can  be  used  in 
the  treatment  of  any  fracture  of  the  thigh  or  leg. 


420 


MANUAL    OF    SURGEEY 


In  children  Bryant's  method  may  be  used;  the  h'mb  is  splinted, 
flexed  to  a  right  angle  with  the  body,  and  extension  made  from  a 
cross  bar  above  the  bed  (Fig.  214).  The  child  may  be  fastened  to  a 
Bradford  frame,  which  is  simply  an  oblong  of  gas  pipe  to  which  can- 
vas is  attached,  a  space  being  left  beneath  the  buttocks.  Van 
Arsdale's  triangular  splint  is  made  of  thick  cardboard,  in  the  shape 
^  of  two  cards  of  spades  joined  at  their  apices  (Fig. 

215).  When  the  splint  has  been  folded,  it  forms 
a  triangle,  segment  2  being  molded  to  the  abdo- 
men and  segment  3  to  the  thigh.  ''The  extreme 
flexed  position  of  the  thigh  relaxes  all  the  muscles 
and  neutralizes  any  tendency  to  displacement; 
the  child  can  sit  on  the  floor  or  chair  and  creep 
about,  and  the  genital  and  anal  regions  are  well 
away  from  the  dressings"  (Gallant).  The  splint 
is  worn  for  three  weeks. 

The  prognosis  in  childhood  is  very  good,  but 
decreases  with  the  advance  of  years,  so  that  in 
adult  life  probably  only  one-half  secure  limbs 
which  give  them  no  trouble,  and  in  old  age  per- 
fect functional  results  are  very  rare.  Except- 
ing incomplete  fractures,  some  shortening  is 
inevitable. 

Supracondylar  fracture  of  the  femur  is  identi- 
cal with  fracture  of  the  lower  third  of  the  bone. 

,      ,  ,        T-  or  Y-shaped  fracture  exists  when  a  sup- 

band  passing  around  ^  t" 

the  injured  thigh  and  racoudylar  fracture  is  complicated  by  a  separa- 

under  the  sound  thigh;      .  ,      ,  .    ,  .  -i  -i  rm 

(c)  of  traction  on  upper  tiou  ot  the  coudylcs  ouc  from  the  other.  The 
end  of  lower  fragment,  Iq^^qx  end  of  the  f cmur  is  broadened,  one  condyle 

by  band  passing  around  _  '  _  -^ 

the  thigh  ;(d)  of  traction  may  be  movcd  ou  the  other  with  crepitus,  and 
Each'^of°these^  bands  ^^^  knee  joiut  is  filled  with  blood.  The  treatment 
passes  over  a  pulley  at  jg  that  of  fracturc  of  the  lowcr  third  of  the  femur. 

the  side  of  the  bed  and  ^^         ,  e       •,-,  i    i       •         i  i  r 

is  attached  to  a  weight.  Fracture  of  either  condyle  is  the  result  of 
The  upper  end  of  the  jj^.^  ^  f^^^^      ^j^^  fragment  is  displaced  upward 

distal  fragment  IS  forced  o  f  f 

outward  also  by  adduct-  and  the  leg  deviated  toward  the  affected  side; 
^"^        ^     '  there  are  crepitus,  broadening  of  the  lower  end 

of  the  femur,  and  distention  of  the  joint,  but  no  shortening.  The 
treatment  is  a  double-inclined  plane. 

Separation  of  the  lower  epiphysis  occurs  before  the  twenty-first 
year,  is  the  most  frequent  of  all  epiphyseal  separations,  and  is  usually 
the  result  of  the  leg  being  caught  in  the  spokes  of  a  wheel.  The 
symptoms  are  much  hke  those  of  supracondylar  fracture,  except  that 


Fig.  213. — Barden- 
heuer's  method  of  treat- 
ing fractures  of  the 
femur,  (a)  Direction  of 
traction  by  Buck's  ex- 
tension apparatus;  (b) 
of  traction  on  lower  end 
of  upper  fragment,   by 


BONES 


421 


the  crepitus  is  moist,  and  the  lower  fragment  is  often  displaced  forward 
owing  to  the  action  of  the  quadriceps  on  the  tibia;  the  lower  end  of  the 
diaphysis  passes  backward,  thus  endangering  the  popliteal  vessels. 


Fig.   214. — Vertical  traction  as  used  in  treatment  of  fracture  of  femur  in  children  or  in 
adults  with  anterior  displacement  of  upper  fragment. 


Suppuration  may  occur  and  the  growth  of  the  bone  may  be  impaired. 
The  treatment  is  reduction  by  traction  while  pressure  is  made  on  the 
fragments  and  the  thigh  gradually  flexed.  The  limb  is  then  put  on  a 
double-inclined  plane. 

Longitudinal  fractures  entering  the 
knee  joint  may  cause  broadening  of  the 
bone,  but  are  difficult  to  detect.  The  treat- 
ment is  immobilization  in  a  horizontal  posi- 
tion for  six  or  eight  weeks.  Occasionally 
a  small  piece  of  the  articular  surface  of 
one  of  the  condyles  is  chipped,  but  unless 
an  X-ray  picture  is  taken,  the  diagnosis  is 
rarely  made  until  some  time  later,  when 
a  foreign  body  is  detected  in  the  joint. 

Fracture  of  the  patella  is  produced  by  direct  violence,  or  much 
more  frequently  by  muscular  action.  Fractures  by  direct  violence  are 
usually  vertical  or  oblique,  and  not  infrequently  comminuted.  As  a 
rule  the  fibrous  capsule  of  the  patella  is  not  separated  to  any  great 


Pig.  215. — Segments,  i,  2,  3, 
4,  each  cut  the  length  of  child's 
thigh  from  groin  to  patella,  and 
flanges  C  to  D  the  same  width. 
The  width  of  sections  i  and  4 
equals  thickness  of  the  middle 
of  the  thigh.  Fold  on  dotted 
lines  overlapping  i  and  4  after 
moistening.  (.A.nnals  of 
Surgery.) 


42  2  MANUAL    OF    SURGERY 

extent  so  that  marked  displacement  is  absent.  The  treatment  of 
these  cases  is  immobihzation  of  the  knee  by  a  posterior  spHnt  for  six 
weeks.  Effusion  into  the  joint  is  reduced  by  cold  and  compression 
and  later  by  massage;  in  four  weeks  gentle  passive  motion  is  begun. 

Fractures  due  to  muscular  action  are  transverse  or  slightly  oblique, 
the  fibrous  capsule  usually  tearing  so  that  marked  separation  takes 
place.  The  joint  is  therefore  usually  opened.  When  the  knee  is 
half  flexed,  the  middle  of  the  patella  lies  against  the  condyles  of  the 
femur,  while  the  upper  portion  projects  above ;  in  this  position  sudden 
contraction  of  the  quadriceps,  as  in  an  attempt  to  save  oneself  from  a 
fall,  may  result  in  a  transverse  fracture.  The  symptoms  are  pain, 
effusion  of  blood  into  the  knee  joint,  inability  to  extend  the  leg 
although  walking  backward  is  possible,  separation  of  the  fragments, 
and  if  they  can  be  brought  together,  crepitus.  The  separation  is 
produced  by  the  action  of  the  quadriceps  and  also  by  the  effusion 
in  the  knee  joint. 

The  treatment  is  at  first  the  application  of  a  posterior  splint,  with 
cold  and  compression  to  reduce  the  swelling.  If  there  is  great  disten- 
tion of  the  joint,  the  effusion  may  be  drawn  off  by  a  trocar  and  can- 
nula. After  the  swelling  has  been  controlled  the  fracture  may  be 
treated  by  the  non-operative  method  or  by  operation. 

The  non-operative  method  is  without  risk  to  life  and  is  generally 
followed  by  a  useful  joint,  although  it  consumes  more  time  than 
treatment  by  operation.  It  should  be  employed  by  the  general 
practitioner  who  is  not  surrounded  by  facilities  for  perfect  asepsis. 
Cases  in  which  the  fibrous  capsule  of  the  patella  and  the  lateral 
fascial  expansions  are  not  torn  through,  i.e.,  cases  in  which  there  is 
but  little  or  no  separation,  are  best  treated  by  the  conservative  plan 
no  matter  what  the  surroundings.  The  limb  is  placed  on  a  posterior 
splint,  the  lower  end  of  which  is  elevated  to  relax  the  quadriceps, 
and  the  fragments  are  approximated  and  held  in  place  by  two  strips 
of  adhesive  plaster,  one  of  which  passes  from  below  the  joint  on  the 
outside,  above  the  upper  fragment,  then  down  to  the  inner  side  of  the 
lower  part  of.  the  knee.  The  second  strip  in  a  similar  way  carries 
the  lower  fragment  upward.  A  third  strip  should  be  put  across  the 
line  of  fracture  to  prevent  tilting  of  the  fragments.  Hopkins  applies 
to  the  thigh  a  wickerwork  of  adhesive  plaster,  to  which  is  attached 
an  extension  apparatus  in  order  to  relax  the  quadriceps  and  pull 
down  the  upper  fragments.  Agnew's  splint  (Fig.  195)  is  simply  a 
posterior  splint  with  rotating  pins  on  the  side  for  the  attachment  and 
tightening  of  the  strips  of  adhesive  plaster  applied  to  hold  the  frag- 
ments in  place.     Massage  may  be  used  from  the  beginning.     During 


BONES 


423 


the  tifth  or  sixth  week  the  splint  may  be  removed,  and  the  patient 
allowed  to  walk  with  a  molded  support  to  keep  the  knee  stiff ;  passive 
motions  are  used  at  this  time,  but  active  movements  are  reserved 
until  the  end  of  two  months;  all  support  is  removed  at  the  end  of  six 
months. 

The  operative  treatment  of  fracture  of  the  patella  is  gaining  in  favor, 
and  indeed  with  some  surgeons  is  almost  routine  practice.  It  should 
never  be  employed  unless  facilities  for  aseptic  work  are  available,  as 
infection  of  the  knee  joint  may  result  in  its  destruction,  in  amputation 
of  the  limb,  or  in  death.  Convalescence  is  more  rapid  after  the 
operative  treatment,  and  it  offers  the  best  chance  for  accurate 
apposition  and  bony  union.  Granting  a  healthy  subject,  it  is  par- 
ticularly indicated  in  cases  in 
which  there  is  wide  separation,  in 
which  soft  tissues  intervene  bo 
tween  the  fragments  after  their 
apposition,  and  in  cases  of  com- 
pound fracture,  re^racture,  or 
fibrous  union  in  which  the  func: 
tion  of  the  limb  is  considerably  im 
paired.  In  the  laborer  or  in  on» 
whose  occupation  necessitates  pro 
longed  standing  or  much  walking, 
operation  offers  the  best  chance  for 
a  strong  patella.  Operative  treat- 
ment may  be  either  subcutaneous  or 
open.  As  an  example  of  the 
former  may  be  mentioned  the 
antero-posterior  suture  of  Barker. 
A  special  instrument  somewhat 
like  an  aneurysm  needle  sharpened  at  the  end  is  passed  through  a 
knife  puncture  just  below  the  patella,  then  beneath  the  bone  to  and 
through  the  skin  above  the  upper  fragment,  where  it  is  threaded  with 
silver  wire  and  withdrawn  to  the  point  of  entrance  and  unthreaded ; 
it  is  then  pushed  upward  between  the  skin  and  the  fragments  to  the 
opening  above,  threaded  with  the  other  end  of  the  wire,  and  with- 
drawn. After  rubbing  the  fragments  together  to  dislodge  blood  or 
soft  tissues,  the  ends  of  the  wire  are  twisted,  cut  short,  and  pushed 
beneath  the  skin.  In  a  somewhat  similar  manner  Roberts  passes  a 
silk  suture  around  the  fragments  laterally  (circumferential  suture). 
The  subcutaneous  possesses  all  the  dangers  of  the  open  method  with- 
out its  advantages,  viz.,   evacuation  of  the  joint,  removal  of  the 


210. — Skiagraph     of 
patella. 


fracture 


424  MANUAL    OF    SURGERY 

fibrous  or  other  tissue  from  between  the  fragments,  and  accurate 
apposition.  The  open  operation  is  performed  by  exposing  the  frac- 
ture by  a  longitudinal  or  transverse  incision,  perferably  the  latter. 
The  joint  is  irrigated  with  salt  solution,  the  fragments  brought  to- 
gether after  removing  any  intervening  soft  structures.  The  wound 
is  closed  without  drainage.  When  the  fragments  come  together 
without  much  tension,  the  fibrous  capsule  of  the  patella  is  sutured 
and  the  lacerations  in  the  lateral  fascial  expansion  with  strong  chro- 
micized  catgut.  If  there  is  a  great  deal  of  tension  it  may  be  neces- 
sary to  pass  kangaroo  tendon  through  vertical  holes  bored  in  the 
fragments.  Massage  is  begun  as  soon  as  the  wound  is  healed,  and 
the  patient  is  allowed  out  of  bed  with  a  molded  splint  at  the  end  of 
three  or  four  weeks,  when  passive  motions  are  commenced ;  all  dress- 
ings are  removed  in  two  months,  and  at  the  end  of  three  or  four 
months  recovery  is  complete. 

The  prognosis  after  non-operative  treatment  is  good  regarding 
the  function  of  the  leg,  although  fibrous  union  is  the  rule  and  some 
stiffness  and  weakness  are  generally  present.  After  operation  bony 
union  may  be  secured,  but  pain  and  stiffness  are  by  no  means  un- 
usual. Of  373  cases  of  fracture  of  the  patella,  48  suffered  a  refracture 
at  the  same  point,  in  periods  ranging  from  a  few  months  to  four 
years;  the  majority  of  these  were  treated  by  the  conservative  plan 
(Lauper) . 

The  tibia  may  be  fractured  at  the  upper  end,  at  any  portion  of  the 
shaft,  and  at  the  lower  end,  and  the  tubercle,  or  the  upper  or  lower 
epiphysis  may  be  separated. 

The  upper  end  of  the  tibia  is  broken  by  direct  violence.  The 
symptoms  are  often  masked  by  the  swelling  of  the  overlying  soft 
parts.  When  the  fracture  is  transverse  there  is  but  little  displace- 
ment, when  oblique  the  leg  deviates  from  the  axis  of  the  Hmb.  The 
fissure  may  enter  the  joint,  which  will  then  be  greatly  distended. 
Mobility  and  crepitus  are  present.  The  treatment  is  reduction  by 
traction  and  pressure  on  the  fragments,  and  immobilization  on  a 
double-inclined  plane  or  in  a  plaster  cast,  for  four  or  five  weeks. 

The  tubercle  of  the  tibia  may  be  torn  off  by  violent  contraction  of 
the  quadriceps,  in  individuals  under  the  age  of  twenty.  The  fragment 
is  drawn  upward,  and  the  injury  may  be  mistaken  for  fracture 
of  the  patella,  in  which,  however,  there  is  no  depression  at  the  upper 
extremity  of  the  tibia,  the  upper  end  of  the  lower  fragment  is  ser- 
rated, and  a  finger  pressed  between  the  fragments  touches  the  femur. 
If  the  separation  is  partial  the  diagnosis  is  made  by  pain,  tenderness, 
localized   swelling,   and   the  X-ray.     The  treatment  is   a  posterior 


BONES 


425 


splint;  if  there  is  much  separation,  the  tubercle  may  be  fastened 
in  place  by  pegging. 

Separation  of  the  upper  epiphysis  of  the  tibia  is  an  extremely  rare 
injury  which  may  occur  before  the  sixteenth  year  and  be  productive 
of  dwartlng  of  the  leg.  The  treatment  is  that  of  fracture  of  the  upper 
end  of  the  tibia. 

The  shaft  of  the  tibia  is  usually  broken  by  direct  violence,  occa- 
sionally by  indirect  violence  or  torsion.  Generally  speaking  the 
fracture  is  transverse  when  in  the  upper  part  of  the  bone,  oblique  or 
spiral  when  in  the  lower  portion  (Fig.  217).  The  symptoms  are 
localized  pain,  irregularity  of  the  crest  of  the  tibia,  crepitus,  and 
mobility.  In  transverse  fractures  there  may 
be  no  deformity,  and  even  in  obhque  frac- 
tures the  splinting  action  of  the  fibula  may 
prevent  much  displacement;  as  a  rule,  how- 
ever, the  upper  fragment  is  tilted  forward  by 
the.  quadriceps,  while  the  lower  fragment  is 
rotated  inward.  The  treatment  is  the  applica- 
tion of  a  fracture  box  (Fig.  195),  until  the 
swelling  has  been  controlled  by  evaporating 
lotions  or  the  ice  bag;  the  leg  is  then  put  up 
in  a  plaster-of-Paris  cast,  which  is  worn  for 
five  weeks.  The  cast  should  be  split  before 
it  has  hardened,  so  that  it  may  be  removed 
every  few  days  for  inspection  and  massage 
of  the  leg. 

The  internal  malleolus  is  broken  by  direct 
force,  or  its  tip  may  be  torn  off  by  the  in- 
ternal lateral  ligament  when  the  foot  is 
strongly  everted.  The  symptoms  are  pain, 
mobility,   crepitus,  effusion  into   the   ankle 

joint,  and  possibly  downward  displacement  of  the  fragment.  The 
treatment  is  that  of  fracture  of  the  shaft.  Wiring  or  pegging  should 
be  considered  if  there  is  much  displacement,  as  vicious  union  in  this 
situation  is  followed  by  lameness. 

Separation  of  the  lower  epiphysis  of  the  tibia  is  very  rare.  The 
treatment  is  that  of  fracture  of  the  shaft. 

The  fibula  may  be  broken  by  direct  or  indirect  force,  or  by 
muscular  action  (biceps). 

The  upper  end  of  the  fibula,  when  broken,  causes  localized  pain, 
particularly  on  adduction  of  the  leg.  There  may  be  no  displace- 
ment, or  the  upper  fragment  may  be  drawn  up  by  the  biceps.     Crepi- 


FiG.    217. — Skiagraph     of 
torsion  fracture  of  tibia. 


426  MANUAL    OF    SURGERY 

tus  and  mobility  are  present;  the  external  popliteal  nerve  may  be 
injured.  The  treatment  is  the  application  of  a  plaster  cast  for  five 
weeks.  If  there  is  displacement  the  knee  may  be  flexed  to  relax  the 
biceps. 

The  shaft  of  the  fibula,  when  broken,  causes  localized  pain  and 
tenderness.  Deformity  is  not  seen,  but  on  pressing  the  tibia  against 
the  fibula,  crepitus  and  abnormal  mobihty  may  be  detected.  As  the 
bone  is  normally  elastic,  comparison  with  the  other  leg  should  be 


Fig.  2 1 8. — Pott's  fracture. 

made   before   deciding   that   abnormal  mobility   is   present.     The 
treatment  is  a  plaster  cast  for  five  weeks. 

The  lower  end  of  the  fibula  may  be  broken  by  direct  force,  but  the 
usual  cause  is  a  twist  of  the  foot.  Pott's  fracture  is  caused  by  ever- 
sion  and  abduction  of  the  foot,  rarely  by  inversion  and  adduction. 
In  a  typical  case  there  are  three  lesions,  a  fracture  of  the  fibula  about 
three  inches  above  the  tip  of  the  malleolus,  a  fracture  of  the  internal 
malleolus  due  to  traction  of  the  internal  lateral  ligament  (or  rupture 


BONES  427 

of  the  ligament),  and  rupture  of  the  tibiofibular  ligament  (or  avul- 
sion of  that  part  of  the  tibia  to  which  it  is  attached) .  The  number 
of  lesions  and  consequently  the  amount  of  deformity  depend  upon 
the  degree  of  eversion  and  abduction.  In  the  slighter  forms  the 
internal  malleolus  alone  is  broken  or  the  internal  lateral  ligament 
ruptured.  Continuation  of  the  force  presses  the  astragalus  against 
the  external  malleolus  and,  with  the  tibiofibular  ligament  as  a  ful- 
crum, breaks  the  fibula  above  the  ankle  by  indirect  force,  the  upper 
end  of  the  fragment  passing  toward  the  tibia.  These  injuries  cause 
simply  marked  eversion  of  the  foot.  If  the  tibiofibular  ligament 
also  ruptures,  or  the  tibia  to  which  it  is  attached  gives  way,  there  is 


Pig.  219. — Skiagraph  of  fracture-dislocation  of  ankle. 

added  displacement  of  the  foot  upward  and  backward;  to  this 
variety  the  term  fracture-dislocation  (Fig.  219)  may  be  properly 
applied.  If  the  outward  dislocation  is  complete  the  injury  is  called 
Dupuytren's  fracture.  Occasionally  the  fracture  of  the  fibula  is 
accompanied  by  a  transverse  fracture  of  the  tibia  immediately  above 
the  inner  malleolus,  in  which  case  the  projection  of  the  lower  end 
of  the  upper  fragment  of  the  tibia  may  be  mistaken  lor  the  internal 
malleolus.  In  Pott's  fracture  by  inversion  the  astragalus  presses 
against  and  fractures  the  internal  malleolus,  and  the  fibula  is  broken 
above  the  ankle  by  the  violent  traction  on  the  external  lateral 
ligament,  the  tibiofibular  joint  acting  as  a  fulcrum. 


428 


MANUAL    OF    SURGERY 


The  symptoms  in  a  typical  case  are  aversion  of  the  foot  with 
displacement  upward  and  backward.  There  is  great  sweUing, 
the  ankle  joint  being  distended  with  blood.  The  internal  malleolus 
is  prominent,  the  ankle  joint  widened,  and  the  foot  shortened,  i.e., 
from  the  tibia  to  the  toes.  There  are  three  points  of  great  tender- 
ness, corresponding  with  the  three  lesions  mentioned  above;  the 
joint  can  be  moved  laterally  and  antero-posteriorly,  and  crepitus 
obtained. 


Fig.   220. — Fracture  of  both  bones  of  the  leg. 

The  treatment  is  reduction  by  carrying  the  foot  inward,  forward, 
and  downward,  and  the  application  of  a  fracture  box  until  the 
sweUing  has  been  controlled.  The  foot  is  fastened  to  the  foot-piece 
of  the  box  by  a  bandage,  and  pads  so  arranged  as  to  maintain  reduc- 
tion, relaxation  of  the  tendo  Achillis  and  prevent  pressure  on  the 
heel.  When  the  swelhng  has  subsided,  the  leg  may  be  put  up  in 
plaster,  care  being  taken  to  maintain  the  foot  at  right  angles  to  the 
leg  and  slightly  adducted,  and  to  continue  extension  on  the  foot  until 

the  plaster  has  hardened.  The 
cast  is  permanently  removed  at 
the  end  of  the  fifth  week.  Du- 
puytren's  splint  is  a  straight 
board  extending  from  the  knee 
to  five  or  six  inches  below  the 
foot.  The  lower  extremity  is 
notched.  The  splint  is  applied 
to  the  inner  surface  of  the  limb, 
after  being  thickly  padded  down  as  far  as  a  point  corresponding 
to  the  internal  malleolus,  so  that  the  foot  may  be  inverted  over  the 
lower  end  of  the  pad  by  bandages,  extending  from  the  foot  to  the 
serrations  in  the  end  of  the  spHnt  (Fig.  195).  This  splint  is  well 
suited  to  cases  in  which  there  is  eversion  and  upward  displace- 
ment, but  does  not  correct  backward  displacement  of  the  foot.  If 
reduction  cannot  be  effected  or  maintained,  even  after  flexion  of  the 
knee  or  division  of  the  tendo  AchilHs,  fixation  of  the  fragments  by 
operation  is  indicated. 


Fig.  221. — Traction  by  means  of  a  stock- 
ing glued  to  the  foot  and  ankle. 


BONES  429 

Fracture  of  the  shafts  of  both  bones  of  the  leg  (Fig.  220)  may  be 
due  to  direct  violence,  in  which  case  the  fracture  may  be  transverse 
and  at  the  same  level  in  each  bone;  indirect  violence  frequently 
produces  an  obhque  or  a  spiral  fracture  at  about  the  junction  of  the 
middle  and  lower  thirds  of  the  tibia,  the  fibula  yielding  at  a  higher 
level.  All  the  symptoms  of  fracture  are  in  evidence.  As  a  rule  the 
lower  fragments  pass  up  behind  the  upper  fragments,  owing  to  the 
action  of  the  calf  muscles,  and  are  rotated  outward  by  the  weight 
of  the  foot. 

The  treatment  is  reduction  by  flexing  the  knee  to  relax  the  calf 
muscles,  and  traction  on  the  foot  while  the  bones  are  forced  into 
place;  division  of  the  tendo  Achillis  is  occasionally  necessary.  The 
limb  may  then  be  placed  in  a  fracture  box,  and  after  the  subsidence 
of  swelling  in  a  plaster-of-Paris  cast.  Some  surgeons  apply  molded 
lateral  splints,  others  the  Nathan  R.  Smith  anterior  splint.  Stein- 
mann  employs  "nail  extension"  (p.  419),  the  nails  being  driven  into 
the  malleoli.  The  caliper  is  to  be  preferred.  The  ambulatory 
treatment  also  may  be  used  in  this  region.  Splints  may  be  removed 
in  five  or  six  weeks.  Whatever  treatment  is  employed,  one  should 
guard  against  rotation  of  the  lower  fragments  and  shortening; 
the  former  is  absent  if  the  inner  surface  of  the  great  toe,  the  in- 
ternal malleolus,  and  the  inner  edge  of  the  patella  are  in  the  same 
plane. 

The  prognosis  of  fractures  of  the  leg  in  the  young  is  quite  favorable ; 
in  adult  life,  and  more  so  in  old  age,  pain,  stiffness,  and  swelling  may 
be  present  for  many  months.  Next  to  the  patella  and  humerus  non- 
union is  more  frequent  in  this  region  than  anywhere  else.  After  a 
classical  Pott's  fracture  some  stiffness  of  the  ankle  and  deformity 
are  almost  inevitable.  To  prevent  eversion  of  the  foot  tapering 
wedges  should  be  placed  along  the  inner  edge  of  the  shoe,  ^{q  inch 
in  the  heel  and  }i  inch  thick  in  the  sole.  Should  the  eversion  per- 
sist there  will  be  traumatic  flat-foot,  which  will  necessitate  a  support 
to  the  instep,  or  possibly  in  some  cases  osteotomy  of  the  tibia  and 
fibula. 

Fracture  of  the  astragalus  is  due  to  direct  violence  or  to  a  fall  on 
the  sole  of  the  foot.  Many  of  the  slighter  forms  are  incorrectly 
diagnosticated  as  sprains  of  the  ankle,  as  there  are  pain  and  great 
swelling.  In  the  absence  of  deformity  and  crepitus  a  correct  diagno- 
sis can  be  made  only  with  the  X-ray.  There  are  often  associated 
lesions  of  neighboring  bones.  The  trejtment  is  a  fractuie  box,  and 
later  a  plaster-of-Paris  cast  for  five  weeks. 


43°  MANUAL    OF    SURGERY 

The  OS  calcis  is  usually  broken  by  a  fall  on  the  foot,  and  rarely 
from  violent  contraction  of  the  calf  muscles.  The  Hne  of  fracture 
may  be  in  almost  any  direction;  if  in  the  anterior  portion  of  the  bone 
there  may  be  no  deformity,  if  through  the  sustentaculum  taU  there 
will  be  flattening  of  the  foot,  and  if  more  posterior  the  fragment  may 
be  drawn  up  by  the  calf  muscles.  In  the  latter  instances  crepitus 
and  mobility  may  be  detected.  The  heel  is  often  enlarged  from  side 
to  side.  Cotton  lays  the  inner  side  of  the  foot  upon  a  sand  bag, 
places  felt  over  the  outer  side  of  the  os  calcis  and  impacts  the  frag- 
ments by  blows  from  a  mallet.  Impaction  is  employed  only  after 
the  position  has  been  carefully  corrected  by  manipulation  or  exten- 
sion with  tongs.  The  treatment,  in  the  absence  of  deformity,  is  a 
fracture  box,  and  later  a  removable  plaster-of-Paris  cast  for  four 
weeks.  Widening  of  the  heel  may  be  corrected  with  lateral  pads, 
flattening  of  the  foot  with  an  instep  support.  When  the  posterior 
fragment  is  drawn  upward,  the  tendo  Achillis  may  be  cut,  or  the 
knee  bent,  and  the  foot  fixed  in  plantar  flexion  by  a  slipper  whose  heel 
is  connected  with  the  thigh  by  a  cord.  Far  more  satisfactory, 
however,  is  wiring  or  pegging  the  fragment  in  place. 

The  remaining  bones  of  the  tarsus  may  be  broken  by  direct 
violence,  which  is  usually  of  such  a  nature  as  to  cause  an  open  wound 
and  comminution  of  bone,  hence  excision  of  fragments  with  drainage, 
or  in  some  cases  amputation,  is  required. 

The  metatarsal  bones  may  be  broken  by  direct  or  indirect  vio- 
lence. Tlpie  fracture  is  frequently  compound.  The  usual  symptoms 
of  fracture  are  present.  The  treatment  is  a  molded  splint  for  four 
weeks.  The  treatment  should  be  supplemented  by  the  use  of  felt 
pads  in  the  sole  of  the  shoe  so  shaped  as  to  preserve  the  arches  of 
the  foot. 

Fractures  of  the  phalanges  of  the  foot  are  usually  compound,  and 
often  require  amputation.  In  other  cases  the  toes  should  be  fixed 
on  a  molded  sphnt  of  cardboard,  extending  well  up  on  the  sole  of  the 
foot. 

DISEASES  OF  BONES 

Inflammation  of  bone  begins  in  the  periosteum  or  the  medulla , 
from  which  structures  the  osseous  tissue  receives  its  blood  supply. 
The  phenomena,  viz.,  hyperemia,  exudation,  and  changes  in  the 
perivascular  tissues  are  much  the  same  as  in  other  structures,  except 
that  death  of  the  bone  is  more  likely  to  ensue,  owing  to  the  unyielding 
character  of  the  canals  in  which  the  vessels  run.  Inflammation  here 
as  elsewhere  terminates  in  resolution,  new  growth  {condensing  ostitis, 


BONES  431 

or  osteosclerosis),  or  death  of  the  part.  Death  of  bone  is  brought 
about  by  ulceration  {caries,  inflammatory  osteoporosis,  or  inflam- 
matory rarefaction) ,  abscess  formation,  or  gangrene  {necrosis) .  Ana- 
tomically, inflammation  of  bone  may  be  divided  into  periostitis, 
ostitis,  and  myelitis;  clinically,  however,  periostitis  is  always  linked 
with  inflammation  of  the  subjacent  bone,  myelitis  with  involvement 
of  the  surrounding  osseous  tissue,  hence  the  terms  osteoperiostitis  and 
osteomyelitis  are  more  nearly  correct. 

Osteoperiostitis  (periostitis)  may  be  acute  or  chronic,  localized  or 
diffuse.  In  the  acute  form  the  periosteum  is  red  and  swollen.  This 
is  followed  by  resolution  {simple  periostitis) ,  by  suppuration  {puru- 
lent periostitis),  or  by  permanent  thickening  owing  to  the  deposition 
of  new  bone  {ossifying  or  osteo plastic  periostitis) . 

Periostitis  serosa  or  albumitiosa  (Oilier  and  Poncet)  is  a  variety  of 
suppurative  periostitis,  probably  due  to  organisms  of  low  virulence. 
A  serous  or  mucoid  exudate,  rich  in  albumen  and  containing  staphy- 
lococci or  streptococci  forms  beneath  the  periosteum.  The  course  is 
subacute  or  chronic.  In  old  cases  there  is  Httle  tenderness  and  the 
condition  may  be  mistaken  for  a  cyst  or,  when  on  the  skull,  for  a 
meningocele. 

The  causes  of  osteoperiostitis  are  contusions,  wounds  (including 
fracture),  extension  from  neighboring  tissues,  and  infection  by  way 
of  the  blood,  such  as  rheumatism,  gout,  gonorrhea,  syphiHs,  pyemia, 
tuberculosis,  and  acute  infectious  fevers.  Periostitis  may  occur  also 
at  the  point  of  attachment  of  muscles  which  are  used  to  an  abnormal 
extent,  or  as  the  result  of  pressure,  e.g.,  periostitis  of  the  os  calcis  in 
flat  foot.  Marie's  disease,  or  pulmonary  hypertrophic  osteoarthro- 
pathy, is  an  enlargement  of  the  bones  of  the  forearms,  hands,  legs, 
and  feet  from  ossifying  osteoperiostitis,  and  occurs  in  association 
with  chronic  lung  disease. 

The  symptoms  are  aching  pain,  worse  at  night  and  increased  by 
pressure,  palpable  thickening  of  the  periosteum  in  subcutaneous 
bones,  and,  in  the  event  of  suppuration,  edema  and  redness  of  the  skin 
and  later  softening  of  the  swelHng.  After  the  abscess  has  been 
opened,  denuded  bone  may  be  felt,  which,  as  a  rule,  undergoes  caries 
or  necrosis  to  a  variable  extent,  and  is  removed  by  the  surgeon  or 
separated  by  nature.  In  the  presence  of  suppuration  there  will  be 
constitutional  symptoms  of  sepsis.  In  chronic  periostitis,  in  the 
absence  of  suppuration,  there  may  be  no  symptoms  but  a  tender 
swelHng  of  the  bone.  Ossifying  periostitis  m^ay  produce  exostoses  or 
osteophytes,  particularly  about  a  chronically  inflamed  joint. 

The  treatment  of  acute  periostitis  is  rest,  elevation,  and  cold 


432  MANUAL    OF    SURGERY 

locally.  Constitutional  treatment  is  directed  toward  any  existing 
diathesis.  Suppuration  demands  incision  and  drainage.  Chronic 
periostitis  is  treated  by  mercurial  ointment  locally,  and  potassium 
iodid  internally,  even  in  the  absence  of  a  syphilitic  taint.  The  cause 
should,  of  course,  be  removed  if  possible.  Removal  of  newly 
formed  bone  or  osteophytes  is  occasionally  indicated. 

Acute  osteomyelitis  is  also  described  by  some  authors  under  the 
following  headings:  acute  infective  osteomyelitis,  acute  septic 
osteomyelitis,  acute  diffuse  infective  periostitis,  acute  diaphysitis, 
acute  panostitis,  acute  necrosis.  Perhaps  panostitis  is  the  best  term, 
as  all  the  structures  of  the  bone  are  sooner  or  later  involved. 

The  cause  is  always  infection  by  micro-organisms,  among  which 
are  the  staphylococcus,  streptococcus,  pneumococcus,  gonococcus, 
typhoid  bacillus  and  the  bacillus  coli  communis.  Bacteria  may 
gain  entrance  through  a  wou"nd,  e.g.,  in  compound  fracture,  amputa- 
tion, osteotomy,  etc.;  or  infection  may  extend  from  neighboring 
tissues,  or  come  by  way  of  the  blood,  e.g.,  in  infectious  fevers,  not- 
ably measles  and  scarlet  fever.  Typhoid  osteomyelitis  is  always 
subacute  or  chronic.  When  osteomyelitis  occurs  in  a  healthy 
individual  without  an  open  wound,  the  organisms  are  supposed  to 
have  entered  the  blood  through  the  tonsils,  or  through  the  respiratory, 
intestinal,  or  genitourinary  mucous  membranes.  In  some  of  these 
cases  chilling  of  the  body,  or  a  strain,  sprain,  or  contusion,  precedes 
the  outbreak  of  symptoms.  Children  are  peculiarly  liable  to  this 
form  of  osteomyelitis,  the  process  usually  starting  in  the  end  of  the 
diaphysis,  rarely  in  the  epiphysis  {acute  epiphysitis).  The  neighbor- 
ing joint  is  apt  to  be  involved  if  the  epiphyseal  line  lies  within  the 
capsule  {acute  infantile  arthritis),  as  in  the  hip  and  elbow  joints.  In 
the  diaphyseal  end  of  growing  bone,  or  metaphysis  as  it  is  sometimes 
called,  the  vessels  are  arranged  in  terminal  loops,  which  retard  the 
blood  stream  and  favor  the  deposition  of  organisms;, moreover,  this 
region  is  more  exposed  to  injuries  from  wrenches  or  twists.  The 
favorite  sites  for  osteomyelitis  are  where  the  greatest  growth  in 
length  takes  place,  viz,  the  lower  end  of  the  femur,  the  upper  end  of 
the  tibia,  the  upper  end  of  the  humerus,  and  the  lower  end  of  the 
radius.  Although  it  is  possible  for  the  mildest  cases  to  terminate 
without  suppuration,  such  an  event  is  of  rare  occurrence.  As  a 
rule  suppuration  of  the  medulla  occurs,  and  pus  appears  in  the  Haver- 
sian canals  and  finally  lifts  the  periosteum  from  the  bone,  or  escapes 
through  the  epiphyseal  line,  thence  infiltrating  the  surrounding 
tissues.  Necrosis  of  a  portion  or  of  even  the  entire  shaft  follows. 
Involvement  of  more  than  one  bone  is  uncommon  {multiple  osteomye- 


BONES  433 

litis),  and  occasionally  the  disease  reappears  in  the  same  situation 
{osteomyelitis  rccidiva) . 

The  symptoms  are  sudden  in  onset,  generally  beginning  with  a 
chill,  which  is  followed  by  high  fever.  The  limb  is  painful  and 
tender,  and  soon  becomes  hot,  swollen,  and  edematous.  The  super- 
ficial vessels  are  distended,  and  finally  pus  may  make  its  way  to  the 
surface  and  give  rise  to  fluctuation.  If  there  is  a  wound  the  dis- 
charge will  be  copious  and  offensive  and  the  bone  tender.  It  may  be 
possible  to  see  the  thick,  red,  and  separated  periosteum  and  the  fun- 
gous suppurating  medulla.  The  X-ray  may  show  a  subperiosteal 
exudate,  but  acute  osteomyehtis  ought  to  be  recognized  clinically 
long  before  there  is  sufficient  destruction  of  bony  tissue  to  show  in  a 
skiagraph.  The  constitutional  symptoms  are  those  of  septicemia 
or  pyemia,  and  these  may  predominate  and  mask  the  local  pheno- 
mena, so  that  a  diagnosis  of  typhoid  fever,  rheumatism  or  some 
similar  condition  may  be  made.  The  adjacent  joint  is  often  swollen, 
usually  containing  sterile  serum,  sometimes  pus. 

In  the  mildest  cases  of  osteomyehtis  the  only  symptoms  are  pain 
and  slight  fever.  The  so  called  growing  pains  are  supposed  to  be  due 
to  this  cause. 

The  diagnosis  may  be  difficult,  but  is  most  frequently  not  made 
because  of  an  incomplete  or  careless  examination.  Rheumatism 
affects  more  than  one  joint,  the  tenderness  is  most  marked  in  and 
not  above  or  below  the  joint,  the  local  phenomena  are  less  marked, 
and  the  constitutional  symptoms  are  less  serious.  Gonorrheal 
rheumatism  is  preceded  by  gonorrhea  and  does  not  give  tenderness 
in  the  bone.  Typhoid  fever  is  slow  in  onset  and  does  not  present 
local  bony  s}Tnptoms  in  the  early  stages;  the  blood  shows  the  Widal 
reaction,  and  a  leukopenia  instead  of  a  high  leukocytosis.  Tubercu- 
lous arthritis  starts  in  the  metaphysis,  not  in  the  diaphysis;  the  onset 
is  slow,  and  the  local  and  constitutional  symptoms  much  less  severe. 
In  infantile  scurvy  the  bone  is  tender  and  enlarged,  but  many  bones 
are  apt  to  be  involved,  and  there  are  other  evidences  of  rickets, 
with  marked  anemia,  swollen  and  bleeding  gums,  perhaps  a  normal 
temperature  and,  characteristic  radiographic  changes. 

The  prognosis  is  always  grave.  Death  may  occur  from  septic 
absorption  before  the  local  signs  are  well  marked.  Later  dangers 
are  exhaustion  and  amyloid  disease.  The  neighboring  articulation 
may  be  destroyed,  resulting  in  either  ankylosis  or  flail  joint;  growth 
of  the  limb  may  be  checked  from  involvement  of  the  epiphyseal 
cartilage;  or  it  may  be  necessary  to  remove  the  limb  because  of  septic 
symptoms,  or  because  repair  of  the  bone  is  impossible  owing  to 
destruction  of  the  periosteum. 


I 

434  MANUAL   OF    SURGERY 

The  treatment  is  immediate  drainage.  After  making  a  longi- 
tudinal incision  in  the  soft  parts  the  periosteum  is  reflected,  and  the 
medulla  opened  with  a  trephine,  gouge,  or  chisel  (Fig.  222).  Suffi- 
cient bone  is  removed  to  expose  all  the  infected  medulla,  thus  in  some 
instances  it  is  necessary  to  chisel  a  gutter  in  the  bone  almost  from 
one  end  to  the  other.  In  children,  excluding  the  rare  cases  in  which 
the  epiphysis  as  well  as  the  diaphysis  is  diseased,  care  should  be  taken 
not  to  injure  the  epiphyseal  line,  because  of  the  danger  of  interfering 
with  the  growth  of  the  limb.  The  suppurating  medulla  is  removed 
by  gentle  curettage,  in  order  to  do  as  little  harm  as  possible  to  the 
endosteum,  which  may  possibly  have  some  influence  in  subsequent 
repair.  The  wound  is  irrigated  with  Dakin's  solution.  The  use  of 
the  chlorine  antiseptics  is  of  peculiar  value  in  these  cases.  The 
constitutional  treatment  is  that  of  septicemia.  Should  drainage 
and  chemical  sterilization  fail  to  mitigate  the  constitutional  symp- 
toms, amputation  may  be  performed  as  a  life  saving  measure.  The 
treatment  of  the  subsequent  necrosis  is  given  below. 

Chronic  osteomyelitis  (chronic  ostitis)  follows  the  acute  form  or 
is  chronic  from  the  beginning.  To  the  latter  class  belong  the  chronic 
bone  inflammations  caused  by  typhoid  fever,  syphilis,  tuberculosis, 
actinomycosis,  leprosy,  and  glanders.  Typhoidal  osteomyelitis  usu- 
ally appears  during  convalescence,  the  tibia  and  ribs  being  most 
frequently  affected.  The  infection  may  be  a  pure  one  or  mixed  with 
pyogenic  organisms.  Like  the  gall-bladder  and  spleen,  the  medulla 
of  bones  may  harbor  typhoid  bacilli  for  years  before  causing  trouble. 
Workers  in  wool,  jute,  and  mother-of-pearl  may  breathe  in  particles 
of  these  substances,  which  finally  lodge  in  the  medulla  and  cause 
sudden  painful  swellings  at  or  near  the  end  of  the  diaphysis;  suppura- 
tion does  not  occur. 

The  S3rmptoms  of  an  osteomyelitis  which  is  chronic  from  the 
start  are  pain,  tenderness,  swelling,  and  but  slight  constitutional 
disturbance.  These  cases  may  terminate  in  suppuration,  or  in 
hypertrophy  of  the  bone  {osteosclerosis,  condensing  ostitis) ;  in  the 
former  the  X-ray  shadows  are  less  dense,  in  the  latter  more  dense 
than  normal. 

The  treatment  is  rest,  ichthyol  or  mercurial  ointment  locally, 
and  iodid  of  potassium  internally.  If  these  measures  fail  or  if  pus 
forms,  the  bone  should  be  opened  and  drained,  except  when  syphilis 
is  the  cause. 

Necrosis,  or  gangrene  of  bone,  is  death  of  a  portion  of  bone  en 
masse.  The  dead  portion  {sequestrum)  varies  in  size  from  a  small 
superficial  flake,  such  as  follows  suppurative  periostitis,  to  a  mass 


BONES 


435 


representing  the  entire  shaft  of  the  bone,  such  as  not  infrequently 
follows  acute  osteomyelitis. 

The  causes  are  acute  and  chronic  inflammations  of  the  periosteum, 
bone  and  medulla.  Removal  of  periosteum  in  the  absence  of  in- 
flammation does  not  induce  necrosis.  Injury  to  the  nutrient  artery 
or  the  lodgment  of  an  embolus  is  rarely  a  cause  of  necrosis.  Phos- 
phorus and  mercury  may  cause  necrosis  of  the  lower  jaw,  particu- 
larly in  the  presence  of  carious  teeth,  which 
permit  infection  of  the  bone  whose  nutrition  is 
altered  by  the  poison.  Quiet  necrosis  is  a  rare 
condition  following  injury;  it  is  unaccompanied 
by  suppuration. 

The  sequestrum  separates  from  the  living 
bone  by  a  line  of  ulceration  or  demarcation 
much  the  same  as  in  gangrene  of  soft  parts. 
The  surrounding  living  bone  usually  undergoes 
a  condensing  ostitis  and  becomes  much  harder 
than  normal.  Small  and  superficial  sequestra 
may  be  discharged  spontaneously  through  a 
sinus,  which  inevitably  exists  in  all  but  very 
small  aseptic  sequestra,  in  which  complete 
absorption  without  suppuration  is  possible.  If 
the  necrotic  mass  is  large  or  centrally  located, 
spontaneous  discharge  is  impossible,  and  sup- 
purative inflammation  may  continue  for  years. 
The  dense  bone  which  surrounds  the  sequestrum 
in  these  cases  is  called  the  involucrum,  and  the 
sinus  leading  from  the  surface  down  to  the 
cavity  in  which  the  sequestrum  lies  is  called  the 
cloaca. 

The  symptoms  of  necrosis  are  a  discharging 
sinus  or  sinuses  which  have  resulted  from  a 
preceding  suppurative  inflammation  of  the  bone. 
The  necrotic  mass  may  be  felt  by  the  probe  or 
demonstrated  by  the  X-ray.  In  a  skiagraph  a  sequestrum,  because 
of  its  porosity,  appears  as  a  light  shadow,  surrounded  by  a  clear 
area,  representing  the  cavity  in  which  it  lies  (Fig.  221). 

The  treatment  in  the  early  stages,  that  is,  after  providing  ample 
drainage  for  the  suppurative  inflammation  which  has  induced  the 
necrosis,  is  frequent  antiseptic  irrigations  and  dressings  until  the 
sequestrum  has  separated,  or  at  least  until  the  destructive  process 
has  reached  an  end.     This  time  varies,  according  to  the  age  and 


Fig.  221. — Skiagraph 
of  chronic  osteomyelitis 
showing  involucrum  and 
sequestrum. 


436 


MANUAL    OF    SURGERY 


general  condition  of  the  patient,  the  size  and  situation  of  the  seques- 
trum, and  the  cause  of  the  necrosis,  from  a  few  weeks  to  several 
months.  In  performing  sequestrotomy,  i.e. ,  removal  of  the  sequestrum, 
the  bone  is  exposed  by  a  suitable  incision,  the  periosteum  retracted, 
sufficient  involucrum  removed  by  gouge  or  chisel,  the  dead  bone 
extracted  with  forceps  (Fig.  222),  and  then  treated  by  chemical 
germicides — preferably   the    chlorin    group.  If   the    sequestrum 

has  not  separated,  the  dead  bone  must  be  chiseled  away.     Dead 


Pig.  222. — (i)  Periostea!  separator,  (2)  lion-jawed  forceps,  (3)  curette,  (4)  seques- 
trum forceps,  (5)  Macewen's  osteotome,  (6)  chisel,  (7)  gotige,  (8)  chain  saw,  (9)  bone 
cutting  forceps. 


bone  is  softer  than  normal,  often  whitish  in  appearance,  and  does 
not  bleed  when  cut.  If  the  cavity  is  small  it  rapidly  fills  with 
granulations,  which  are  ultimately  replaced  by  bone.  If  it  is  large, 
healing  is  very  slow,  hence  the  following  methods  to  assist  repair. 
Dehelley  removes  subperiosteally  more  than  one-half  of  the  bony  wall 
of  the  cavity  which  permits  of  the  filling  of  the  remaining  cavity  by  the 
collapse  of  the  adjacent  soft  tissues.  The  cavity  has  been  filled  with 
aseptic  sponge,  decalcified  bone  chips,  gutta-percha,  plaster-of-Paris, 


BONES  437 

bisnuith  i)aste,  lead,  blood  clot,  mixture  of  i)ararrin  and  iodoform, 
etc.,  but  owing  to  the  presence  of  infection,  such  materials  act 
simply  as  foreign  bodies  and  are  ultimately  discharged.  Recently, 
however,  encouraging  results  have  been  obtained  with  Moorhofs 
hone  wax,  which  consists  of  iodoform  20  parts,  spermaceti  40  parts, 
and  oil  of  sesame  40  parts.  The  cavity  is  rendered  dry  and  sterile, 
and  the  mixture,  heated  to  50°  C,  poured  into  the  cavity  and  allowed 
to  solidify.  Ihe  wax  is  ultimately  absorbed  and  replaced  by  fibrous 
tissue  or  bone.  Neuber  fastens  the  flaps  of  skin  to  the  walls  of  the 
cavity  by  nails  or  stitches,  and  thus  secures  heahng  with  a  trough- 
like depression  lined  with  skin.  Skin  grafting  has  been  used  with  a 
similar  idea.  Nelaton  filled  a  cavity  in  the  clavicle  with  a  peduncu- 
lated flap  of  muscle;  Makkas,  one  in  the  os  calcis  by  the  free  trans- 
plantation of  fat;  Makkas  says  the  fat  is  displaced  later  by  fibrous 
tissue,  which  may  ultimately  ossify.  Transplantation  of  bone  also 
has  been  successfully  performed  to  fill  osseous  defects  (see  p.  449)- 
When  the  periosteum  has  not  been  destroyed,  it  can  confidently  be 
expected  to  replace  even  the  entire  shaft  of  the  bone.  Nichols 
has  recently  investigated  this  subject  and  the  following  is  from  his 
paper:  "The  operation  consists  of  an  incision  through  the  skin  and 
ossified  periosteum  down  to  the  necrotic  shaft,  reflexion  of  the  perios- 
teum, removal  of  the  shaft,  either  entire  or  partial,  folding  of  the 
plastic  periosteum  in  such  a  way  as  to  approximate  the  internal  layers, 
suture  of  the  edges  by  absorbable  sutures,  suture  of  the  soft  tissues, 
with  provision  for  moderate  drainage  and  complete  immobilization." 
The  shaft  is  sufiiciently  solid  for  use  in  from  four  to  eight  months. 
In  regions  such  as  the  thigh  or  arm  where  there  is  no  companion  bone 
to  act  as  a  splint  and  maintain  the  length  of  the  limb,  one  should 
wait  until  the  periosteal  shell  of  regenerating  bone  is  sufficiently 
advanced  to  preserve  the  contour  of  the  limb  and  prevent  shortening. 
This  stage  is  reached  when  the  periosteal  shell  as  determined  by  the 
X-ray  is  equal  in  thickness  to  one-fourth  of  the  diameter  of  the  or- 
iginal shell.  If  delay  is  not  advisable  sequestrotomy  may  be  per- 
formed and  a  magnesium  splint,  or  a  prop  of  bone  obtained  from 
another  portion  of  the  body,  inserted.  In  a  recent  case  of  this 
character  we  maintained  the  length  of  the  femur,  until  new  bone  had 
been  formed,  by  means  of  a  piece  of  sterilized  ox  bone. 

Caries  {inflammatory  osteoporosis,  rarefying  ostitis,  ulceration  of 
bone)  is  molecular  death  of  bone.  The  bone  is  soft  and  honey- 
combed, and  crumbles  when  pressed  upon  by  a  probe.  Caries  is 
the  result  of  inflammation,  particularly  that  form  due  to  syphilis 
or  tuberculosis.     The  ulceration  which  separates  living  bone  from 


438 


MANUAL    OF    SURGERY 


dead  is  a  form  of  caries.  The  spaces  in  carious  bone  (Hou'ship's 
lacuncE)  are  the  result  of  suppuration,  or  absorption  by  large  giant 
cells  {osteoclasts).  Caries  sicca  is  caries  without  suppuration.  In 
caries  Jungosa  there  is  an  excess  of  granulation  tissue.  Caries 
necrotica  is  the  form  in  which  small  crumbHng  fragments  are  dis- 
charged. The  symptoms  of  caries  are  those  of  necrosis,  except 
that  the  probe  detects  rough  and  friable  bone  instead  of  a  firm 
sequestrum. 

The  treatment  is  exposure  of  the  bone,  and  removal  of  the 
diseased  tissue  with  curette  or  gouge,  and  the  treatment  of  the 
ca\-ity  as  described  in  necrosis,  pages  436-437.  The  limits  of  the 
disease  are  reached  when  the  bone  becomes  pink  and  firm  and 
bleeds  on  cutting. 

Tuberculosis  of  bone  may  be  generaHzed  in 
the  course  of  acute  miliary  tuberculosis.  Loca- 
lized tuberculosis  is  most  frequent  in  early  hfe, 
and  usually  follows  infection  in  some  other  por- 
tion of  the  body,  notably  the  lungs  and  the 
l}Tiiph  glands.  In  the  long  bones  the  disease 
usually  begins  in  the  metaphysis  in  children,  in 
the  epiphysis  in  adults;  in  the  other  bones  it 
begins  in  the  periosteum,  or  more  frequently  in 
the  cancellous  tissue.  Tuberculosis  of  the 
„  c  •  phalanges   is    called    tuberculous   dactvUtis,   or 

Fig.  223. — Spina  ven-     -re  ^  ^  ' 

tosa,  so  called  because  of    spina   ventosa    (Fig.    223).     Occasionally    the 

the  flask-like  inflation  of      ,.  ,..  .    .    ^         ,  j-i-  1 

the  bone:  it  may  be  due  diseasc  bcgms  m  a  jomt  and  sccondarily  mvolvcs 
to  any  of  the  causes  of    ^j^g  bone.     The  pathologv  is  much  the  same  as 

bone  inflammation,   but 

is  usually  syphilitic  or  that  of  tuberculosis  elsewhere,  the  tuberculous 
tuberculous.  mass  Undergoing  caseation    and    Hquefaction, 

and  being  surrounded  by  a  zone  of  inflamed  bone.  The  diseased 
bone  may  separate  as  a  sequestrum,  but  as  a  rule  it  under- 
goes caries,  which  progressively  invades  the  surrounding  bone. 
When  the  process  remains  localized  and  undergoes  suppuration, 
it  forms  an  abscess  (Brodie's  abscess),  which  is  Hned  by  a  pyogenic 
membrane  and  surrounded  by  a  zone  of  condensing  ostitis.  Such 
abscesses  are  most  frequent  in  the  ends  of  long  bones,  particularly 
the  tibia  and  femur.  These  abscesses  may  perforate  the  periosteum 
and  infiltrate  the  soft  tissues.  The  term  cold  abscess  is  applied  to 
these  tuberculous  collections  in  the  soft  tissues  see  p.  112.  Trau- 
matism, often  slight  in  nature,  frequently  determines  the  site  of 
the  lesion. 


BONES  439 

The  symptoms  are  boring  i)ain,  tenderness,  and  thickening  of 
the  bone.  The  X-ray  will  show  the  disease  as  soon  as  the  process 
of  disintegration  is  advanced  far  enough  to  lessen  the  density  of 
the  bone  and  long  before  the  clinical  period  of  softening.  If  allowed 
to  progress,  the  disease  invades  the  neighboring  joint,  or  the  pus 
finds  its  way  to  the  soft  parts  about  the  bone  and  finally  presents 
itself  beneath  the  skin,  sometimes  a  long  distance  from  its  point  of 
origin.  After  the  abscess  breaks  or  is  opened,  infection  with 
pyogenic  organisms  causes  hectic  fever,  and  in  neglected  cases  this 
leads  to  exhaustion  or  amyloid  disease. 

The  treatment  is  removal  of  the  diseased  tissue  by  gouge, 
curette,  excision,  except  in  children  under  2  years  of  age,  or  in 
some  cases  even  by  amputation.  Spina  ventosa,  according  to 
Pels-Leusden,  should  be  treated  by  excision  of  the  diaphysis  with 
the  periosteum,  and  transplanting  to  its  place  a  segment  of  the 
tibial  crest  or  a  phalanx  from  a  toe.  In  the  early  stages  of  osseous 
tuberculosis,  before  the  formation  of  pus,  or  in  the  later  stages 
if  the  site  of  the  disease  is  inaccessible,  the  affected  parts  are 
immobihzed  by  plaster-of-Paris  or  by  other  means,  and  a  cure  some- 
times obtained.  Passive  hyperemia,  radiotherapy,  and  heliotherapy 
are  employed  by  some  surgeons. 

Syphilis  of  bone  occurs  in  the  secondary  and  tertiary  periods, 
and  like  tuberculosis,  the  site  is  often  determined  by  trauma.  In 
the  secondary  stage  osteocopic  pains  occur,  apparently  with  no 
organic  change  in  the  bones.  The  periostitis  of  the  second  stage 
results  in  resolution,  rarely  in  suppuration,  and.  most  frequently  in 
ossification  of  the  exudate,  leaving  a  permanent  node.  In  the 
tertiary  stage  the  bone  may  become  the  seat  of  a  condensing  ostitis, 
or  gummata  may  form  in  periosteum,  bone,  or  medulla,  the  skull, 
sternum,  and  tibia  being  the  favorite  sites.  With  appropriate 
treatment,  the  gummatous  material  may  be  absorbed,  but  frequently 
degeneration  occurs  and  the  puruloid  material  ultimately  evacuates 
itself  through  the  skin.  The  bone  is  then  carious  and  worm-eaten, 
and  beyond  this  there  may  be  a  zone  of  sclerotic  osseous  tissue. 
Necrosis  occurs  in  some  cases  (Fig.  224)  owing  to  the  constriction  of 
the  vessels  by  the  surrounding  sclerotic  tissue;  the  sequestra  in  such 
cases  may  not  separate  for  years.  Should  sepsis  supervene,  the 
soft  parts  become  infiltrated  with  foul  smelhng  pus,  which  in  the 
skull  may  spread  to  the  brain  or  its  membranes.  As  in  tuberculosis, 
amyloid  disease  may  appear.  Syphilitic  dactylitis  (Fig.  223)  occurs 
in  the  late  secondary  stage  as  a  periostitis,  or  in  the  tertiary  stage  as 
a  gummatous  osteomyelitis. 


440 


MANUAL    OF    SURGERY 


Congenital  syphilis  produces  the  same  bone  lesions  as  the  acquired 
form.  The  site  of  the  disease,  however,  is  more  often  influenced  by 
rapid  growth  than  by  traumatism,  hence  the  frequency  of  syphilitic 
epiphysitis,  or  osteochondritis  as  it  is  sometimes  called.  The  ends 
of  the  bones  enlarge  in  these  cases,  and  present  some  resemblance  to 
rickets.  The  swellings,  however,  occur  much  earHer  in  Ufe  than 
rickets,  are  associated  with  other  symptoms  of  syphilis,  and  are 
influenced  by  syphihtic  treatment.  Suppuration,  separation  of  the 
epiphysis,  and  deformity  may  follow.  Periosteal  nodes  occur,  and 
when  situated  about  the  anterior  fontanelle  are  called  Parrot's  nodes. 
Craniotabes  is  a  thinning  of  the  calvarium.  which  may  crackle  on 
pressure.     Occasionally  a  bone  is  stimulated  to  overgrowth,*^ and 


Fig.   224. — Syphilitic  necrosis  of  the  skull. 

when  there  is  a  companion  bone,  as  in  the  forearm  or  leg.  marked 
curvature  results. 

The  treatment  is  that  of  syphihs.  Sinuses  should  be  kept  clean 
lest  septic  symptoms  supervene.  Necrotic  or  carious  bone  is 
treated  as  already  indicated. 

Rickets,  or  rachitis,  is  a  constitutional  disease  due  to  malnutri- 
tion, and  often  associated  with  bad  hygienic  surroundings  and 
improper  diet.  It  usually  occurs  during  the  first  three  years  of  Ufe. 
The  so-called  congenital  rickets  is  generally  achondroplasia  or 
osteogenesis  imperfecta. 

The  symptoms  in  the  early  stages  are  disorders  of  digestion, 
anemia,  sweating  about  the  head,  swelling  of  the  abdomen,  and 


BONES 


441 


enlargement  of  the  spleen.  The  important  changes  are  those  in 
the  bones  (Fig.  22-5),  in  which,  although  there  is  an  active  pro- 
liferation of  the  cellular  elements,  prompt  calcification  does  not 
occur.  The  epiphyses  are  swollen  and  tender,  and  the  shafts  of 
the  long  bones  softened.  Later  ossification  occurs,  frequently  with 
deformity.  The  head  becomes  square  and  the  frontal  eminences 
prominent,  the  fontanelles  and  sutures  close 
late,  and  craniotabes  may  occur.  Eruption 
of  the  teeth  is  delayed,  and  they  are  often 
dwarfed,  deformed,  and  the  seat  of  early 
caries.  The  spine  may  become  curved  and 
the  chest  "chicken-breasted."  The  ribs  are 
enlarged  at  their  junctions  with  the  costal 
cartilages  {rachitic  rosary) ,  and  there  may  be 
a  marked  groove  extending  from  the  axilla 
down  toward  the  end  of  the  sternum 
(Harrison  '5  sulcus) .  The  pelvis  may  be  dis- 
torted and  the  limbs  curved,  e.g.,  bow-legs, 
knock-knee,  etc.  Growth  of  the  entire  body 
is  often  defective. 

The  treatment  is  correction  of  the  diet, 
fresh  air,  sunshine,  and  attention  to  the 
bowels,  together  with  cod-liver  oil,  syrup  of 
the  iodid  of  iron  and  hypophosphites.  De- 
formities are  prevented  by  keeping  the 
patient  in  bed,  and  they  are  corrected,  while 
the  bones  are  soft,  by  daily  manipulations 
and  braces.  After  two  or  three  years  de- 
formities usually  require  osteotomy  or  other 
form  of  operation. 

Scurvy  rickets    (acute   rickets,    infantile 
scurvy,  Mceller- Barlow  disease)  is  a  combina- 
tion of  rickets  and  scurvy,  either  of  which    .hfidsix  years  old.  showing 
may  predominate.     It  is  most  frequent  in    the  osseous  changes   of 

rickets 

the  children  of  the  well-to-do,  and  arises  from 

malnutrition  resulting  from  the  administration  of  artificial  foods. 
The  symptoms  of  rickets  may  or  may  not  be  marked  wnen  the 
scorbutic  features  predominate.  There  may  be  spongy,  bleeding 
gums,  and  bleeding  from  the  mucous  membranes,  beneath  the 
skin  or  periosteum,  or  into  the  muscles  or  joints.  An  epiphysis 
is  sometimes  separated  from  a  diaphysis  by  hemorrhage,  and 
the    pain    and    swelling    caused    by    this    or    by  bleeding  beneath 


442  MANUAL    OF    SURGERY 

the  periosteum,  particularly  when  associated  with  fever,  may  be 
mistaken  for  acute  osteomyehtis  (q.v.).  Recovery  occurs  in  91  per 
cent,  of  the  cases.  The  treatment  is  fresh  milk,  beef  or  lime  juice, 
and  the  juice  of  oranges,  lemons,  grapes,  or  apples.  A  painful  limb 
should  be  kept  quiet,  and  in  some  cases  bandaged  or  splinted. 

Achondroplasia  {chondrodystrophia  fetalis,  micromelia)  is  a  rare 
congenital  disease  characterized  by  defective  development  of  certain 
portions  of  the  skeleton.  Death  at  or  soon  after  birth  is  the  rule, 
although  in  a  few  instances  adult  life  has  been  reached.  The  trunk 
is  of  normal  length,  but  the  bones  of  the  limbs  are  short  and  bowed 
and  abnormally  thickened  at  the  points  where  the  muscles  are 
attached.  All  the  fingers  are  of  the  same  length,  and  a  wide  interval 
exists  between  the  second  and  third  finger,  giving  rise  to  the 
"trident  hand."  The  base  of  the  nose  is  depressed  and  the  vault 
of  the  cranium  large,  but  the  intelHgence  is  in  no  way  impaired. 
The  pelvis  is  small,  the  belly  prominent  owing  to  lumbar  lordosis, 
and  the  genitals  normal.  Rickets  differs  from  this  condition  in 
that  it  is  post-natal;  the  bones  are  soft,  not  hard;  the  trunk  is 
affected;  there  is  no  pug  nose;  and  the  cranium  is  bossed.  In 
cretinism  the  intelligence  is  defective,  the  hair  scanty  and  coarse, 
and  the  patients  improve  after  taking  thyroid  extract.  Syphihtic 
pug  nose  is  due  to  bone  disease,  not  to  premature  union  of  the  bones 
at  the  base  of  the  skull  as  in  achondroplasia.  There  is  no  treatment 
for  achondroplasia. 

Atrophy  of  bone  may  be  congenital;  or  it  may  be  due  to  inflam- 
mation, disease  or  injury  of  the  epiphysis;  disuse;  pressure,  e.g., 
from  a  tumor  or  aneurysm;  or  to  disease  or  injury  of  the  nervous 
system,  e.g.,  tabes,  section  of  nerves,  syringomyelia,  paresis  and 
other  forms  of  insanity.  It  is  normal  in  old  age,  as  is  best  seen  in 
the  cranium,  lower  jaw,  and  neck  of  the  femur.  Atrophied  bone 
breaks  easily,  so  that  one  should  bear  the  above  causes  in  mind 
during  forcible  manipulations,  such  as  are  employed  in  breaking 
joint  adhesions,  etc. 

Fragilitas  ossium,  or  osteopsathyrosis,  is  a  condition  in  which 
there  is  an  abnormal  predisposition  to  fractures,  even  from  slight 
force.  There  are  two  forms,  the  idiopathic  and  the  symptomatic. 
Idiopathic  fragilitas  ossium  is  congenital  and  often  hereditary.  In 
some  cases  {osteogenesis  imperjecta)  fractures  occur  before,  during, 
or  soon  after  birth,  and  the  children  are  still-born  or  survive  only  a 
few  months.  In  others  the  tendency  to  fractures  is  most  marked 
between  the  second  and  twelfth  years,  and  usually  disappears  with 
the  advent  of  adult  life.     Union  is  prompt  but  often  with  con- 


BONES 


443 


siderable  deformity.  The  cause  and  pathology  are  not  known.  The 
symptomatic  form  is  due  to  any  of  the  other  conditions  mentioned 
amonu  the  pathological  causes  of  fracture  (p.  375). 

Osteomalacia,  or  mollities  ossium,  is  a  disease  in  which  the 
bones  become  abnormal!}'  flexible  owing  to  the  absorption  of  cal- 
careous material.  It  is  rare  in  the  male  and  peculiarly  frequent  in 
puerperal  women.  The  cause  is  not  known.  The  bones  become 
distorted  and  break  with  greater  ease  than  normally;  in  the  latter 
instance  non-union  often  occurs.  Of  great  importance  is  deform- 
ity of  the  pelvis,  because  of  the  difficulties  which  may  arise  during 
labor.  It  is  usually  compressed  laterally,  the  pubes  passing  for- 
ward, thus  giving  it  a  triangular 
shape.  The  patient  is  weak  and 
emaciated,  and  complains  of 
pain  in  various  parts  of  the 
skeleton.  Death  after  many 
years  is  the  usual  result, 
although  recovery  occasionally 
occurs.  The  treatment  is  tonic 
and  stimulating,  with  phos- 
phates, cod-liver  oil,  and  bone 
marrow^.  Braces  may  be 
needed,  and  means  should  be 
taken  to  prevent  pregnancy. 
Removal  of  the  ovaries  some- 
times results  in  cure. 

Hypertrophy  of  bone  may 
be  congenital,  or  it  may  be  due 
to  increased  use,  e.g.,  w^here 
muscles  are  attached,  or  to  in- 
creased nutrition  the  result  of 

inflammation.  Giant  growth  of  the  fingers  or  toes  {^nacrodactylia), 
of  an  entire  Hmb,  or  of  the  entire  body,  may  be  congenital  or  acquired; 
the  cause  is  not  known.  Progressive  hypertrophy  of  the  bones  of 
the  skull  is  called  leontiasis  ossium  (Fig.  226).  It  begins  in  early 
life,  and  terminates  fatally  after  a  number  of  years,  sometimes  from 
compression  of  the  brain.     No  curative  treatment  is  known. 

Acromegaly  is  a  skeletal  overgrowth  due  to  increased  activity 
of  the  anterior  lobe  of  the  pituitary  body  (hyperpituitarism)  some- 
times induced  by  tumor  or  hypertrophy.  All  parts  of  the  body 
are  enlarged,  particularly  the  forearms,  hands,  legs,  feet,  jaws,  lips 
tongue,  nose,  and  orbital  ridges  (Fig.  227).     The  hands  are  spade 


Fig.  226. — Leontiasis  ossium. 


444 


MANUAL    OF    SURGERY 


shaped,  the  fingers  sausage-hke,  the  jaw  prominent  (prognathism), 
the  teeth  separated,  the  face  triangular  with  the  base  downward 
(the  face  of  Paget 's  disease  is  triangular  with  the  base  upward, 
that  of  myxedema  is  moon-shaped),  and  the  spine  kyphotic,  the 
attitude  of  the  patient  resembhng  that  of  the  gorilla.     The  thyroid 


Fig.  227. — Acromegaly. 

gland  is  often  enlarged  and  arteriosclerosis  is  not  uncommon.  The 
principal  symptoms  are  headache  and  malaise.  Glycosuria  is  some- 
times present.  The  disease  is  fatal,  usually  after  many  years.  The 
treatment  is  symptomatic,  unless  evidences  of  tumor  of  the  pituitary 
body  be  present,  when  its  removal  is  indicated  (see  tumors  of  the 
pituitary  body,  chap,  xxi) . 


BONES 


445 


Ostitis  deformans,  or  Paget  s  disease,  consists  of  enlargement  or 
softening  of  the  bones,  usually  after  the  age  of  forty.  The  cranium 
enlarges  but  the  facial  bones  are  not  involved,  the  face  being  trian- 
gular with  the  base  upward.  The  patient  diminishes  in  height 
owing  to  kyphosis  and  outward  curvature  of  the  lower  extremities. 
The  chest  is  sunken  and  the  pelvis  broadened.  The  patient  com- 
plains of  rheumatic  pains  and  has  an  awkward  gait.  The  disease 
is  very  slow  in  progress.  Multiple  sarcomata  of  the  bones  develop 
in  some  cases.  The  treatment  is  symptomatic,  no  remedies  being 
known. 

Ostitis  fibrosa  (von  Reck- 
linghausen) is  classified  by 
some  writers  with  the  in- 
flammatory, by  others  with 
the  non-infiamma-tory  affec- 
tions of  bone.  Its  cause  is 
unknown,  some  think  that  it 
is  of  infectious  origin,  others 
that  it  is  of  a  syphilitic  or 
parasyphilitic  nature.  There 
is  extensive  lacunar  absorp- 
tion of  the  osseous  tissue  with 
fibrous  changes  in  the 
medulla,  giving  rise  to  a 
whitish  or  brownish-red 
tumor.  This  fibrous  tissue 
usually  melts  down  in  places, 
thus  forming  multiple  cysts 
(Fig.  228)  containing  serous 
or  serosanguineous  fluid 
{ostitis  fibrosa  cystica) ,  but  it 
may  harden  and  ultimately 
ossify  (ostitis  fibrosa  osteo- 
plastica).  The  disease  may  appear  at  any  time  of  life,  and  attack 
one  or  much  more  frequently  a  number  of  bones.  The  affected 
bone  is  enlarged,  often  curved,  and  sometimes  the  seat  of  spontan- 
eous fracture.  The  swelling  may  be  mistaken,  clinically  and  micro- 
scopically, for  giant-celled  sarcoma.  Some  authorities  hold  ostitis 
fibrosa  responsible  for  leontiasis  ossium,  ostitis  deformans,  epulis, 
and  certain  cases  of  fragilitas  ossium.  When  the  disease  is  con- 
fined to  one  bone  recovery  ma}-  follow  curettage  or  excision. 

Tumors  of  bone   may  be   benign   or   malignant.     The  benign 


Fig.  228. — Ostitis  fibrosa  cystica.     (Henderson.) 


446 


MANUAL    OF    SURGERY 


tumors  are  osteoma,  chondroma  (p.  223),  fibroma,  lipoma,  myxoma, 
and  angioma.  The  only  primary  malignant  tumor  of  bone  is 
sarcoma,  although  it  may  be  invaded  secondarily  by  carcinoma 
(especially  from  the  breast,  thyroid,  and  prostate)  and  sarcoma. 
Metastatic  osseous  growths  are  sometimes  the  first  sign  of  hyper- 
nephroma. 


Pig.  229. — Sarcoma  ot  the  femur,  showing  radiating  spicules  of  bone. 

Periosteal  sarcoma  is  of  the  spindle-  or  round-celled  variety, 
grows  rapidly,  and  causes  early  metastases,  although  it  may  undergo 
more  or  less  complete  ossification,  as  shown  in  Fig.  229.  Central 
sarcoma,  beginning  in  the  osseous  tissue  or  medulla,  causes  expansion 
of  the  bone,  and  is  usually  found  near  the  end  of  a  long  bone,  but 
rarely  invades  the  joint.  If  of  the  round-  or  spindle-celled  variety 
the  degree  of  mahgnancy  is  high,  if  giant-celled,  or  myeloid,  it  is 
comparatively  benign.     The   overlying  bone  may  become  so  thin 


BONES  447 

as  to  crackle  on  pressure,  and  spontaneous  fracture  is  not  unusual. 
In  all  forms  of  sarcoma  pulsation  may  occur  owing  to  the  great 
vascularity,  and  some  degree  of  ossification  is  usually  present; 
the  superficial  veins  are  distended  and  clearly  evident  beneath  the 
whitened  skin.  Hemorrhagic  infiltration  and  cystic  degeneration 
are  of  frequent  occurrence. 

The  diagnosis  may  be  very  difficult,  owing  to  the  resemblance 
to  chronic  osteoperiostitis,  ostitis  fibrosa,  or  syphilitic  or  tuberculous 
disease  of  bone.  Sarcoma  grows  steadily,  is  irregular  in  contour 
and  density,  is  apt  to  pulsate,  causes  distention  of  the  superficial 
veins,  and  may  give  a  crackling  sensation  on  pressure  owing  to 
thinning  of  the  bone.  The  X-ray  shadow  of  the  tumor  is  often 
sharply  limited;  it  shows  absorption  of  bone  in  the  more  malignant 
cases,  spicules  radiating  at  right  angles  to  the  bone  in  the  more 
benign  varieties  (Fig.  229).  In  inflammatory  bone  diseases  there 
is  apt  to  be  diffuse  mottling,  surrounded  by  a  dense  shadow  corre- 
sponding to  the  zone  of  condensing  ostitis;  in  syphilis  and  tuberculosis 
this  dense  shadow  may  extend  over  a  large  part  of  the  diaphysis. 
In  ostitis  fibrosa  the  multiple  cysts  may  show  in  the  skiagram  as 
numerous  light  areas. .  Often  a  positive  diagnosis  can  be  made  only 
after  exploratory  incision. 

The  treatment  in  all  but  the  myeloid  form  is  early  amputation 
through  the  next  joint  above.  In  the  myeloid  variety  excision  of  the 
growth  alone  often  results  in  cure,  although  in  some  instances  ampu- 
tation well  above  the  growth  is  required.  Osseous  defects  following 
operation  may  be  filled  by  bone  transplantation. 

Primary  multiple  myelomata  may  arise  simultaneously  in  the 
marrow  of  many  bones,  particularly  those  of  the  trunk  (vertebrae, 
ribs,  sternum) ;  less  frequently  the  skull  and  the  femora  are  affected, 
and  rarely  almost  the  whole  skeleton  is  invaded.  The  tumors 
consist  of  myelocytes,  are  sharply  circumscribed,  and  usually  dark 
red  in  color.  The  bones  may  become  thin  and  bend,  producing 
kyphosis,  etc.,  or  break.  Occasionally  the  growth  extends  to  the 
periosseous  tissues,  and  sometimes  metastases  occur;  myelocytes 
have  been  found  in  the  blood  of  the  liver  and  the  spleen,  the  Bence- 
Jones  body  in  the  urine.  The  patients  ultimately  die  of  exhaustion; 
about  50  cases  have  been  reported. 

Cysts  of  bone  are  usually  due  to  degeneration  of  sarcoma  or  myx- 
oma. Parasitic  cysts  (echinococcus,  cysticercus)  and  dermoid  cysts 
are  rare,  cysts  or  cyst-like  cavities  may  occur  in  ostitis  fibrosa,  perios- 
titis serosa,  osteomalacia,  and  ostitis  deformans.  Cysts  of  the  jaw 
odontomata)  are  described  in  the  chapter  on  tumors. 


448 


MAXUAL    OF    SURGERY 


Large  solitary  cysts  of  long  hones  {osteodystrophia  juvenalis  cystica 
of  ^Mikulicz)  are  the  only  ones  requiring  special  notice  in  this  place. 
The  cyst  is  usually  found  near  the  epiphyseal  Hne  of  a  long  bone 


Pig.  230. — Albee's  armamentarium  for  bone  work.  i.  Calipers.  Doyen  washers 
or  guards  for  motor  saw.  3.  Spray  and  guard  for  saw.  4.  Twin  saw.  5.  Dowelling 
instrument  or  lathe.  6.  Right  angle  twin  saw.  7.  Wrenches  for  twin  saw  and  drill 
chuck.  8.  Drill  with  guard  to  prevent  it  penetrating  too  deeply.  9.  Drill  chuck  and 
small  drill  in  place.  10.  Burr  for  drilling  fractured  neck  of  femur  for  peg  graft.  11. 
Small  circular  saw.  12.  Large  saw.  13.  Carver's  gouge.  14.  Lowman  fracture 
clamp.  15.  Berg  fracture  clamp.  16.  Wide  osteotome  for  splitting  spinous  processes 
for  the  insertion  of  bone-graft  for  Pott's  disease.  17.  Surgical  electric  motor.  18. 
Compasses.     19.  Lambotte  fracture  clamp,  large  and  small. 


(femur,  tibia,  humerus,  less  frequently  metacarpal  or  metatarsal 
bone)  in  an  infant  or  adolescent,  and  often  follows  an  injury.  It  is 
single,  unilocular,  benign,  serous  or  serosanguineous.  and  surrounded 


BONES  449 

by  a  zone  of  ostitis  fibrosa.  There  may  be  pain  and  tenderness,  but 
never  signs  of  inflammation.  The  swcUing  is  ovoid,  regular,  occa- 
sionallv  presents  parchment  crepitation  or  even  fluctuation,  and  is 
sometimes  discovered  only  after  a  spontaneous  fracture.  The  X- 
ray  shows  an  ovoid,  regular,  clear  area,  corresponding  to  the  cyst. 
The  treatment  consists  in  opening  the  cyst,  curettage,  and  gauze 
packing,  or,  as  packing  predisposes  to  infection,  filling  the  ca\dty 
with  fat,  bone  wax,  or  by  one  of  the  other  methods  described  in  the 
treatment  of  necrosis. 

Transplantation  of  bone  may  be  indicated  to  fill  developmental 
defects  (e.g.,  spina  bifida,  congenital  saddle-nose,  absence  of  radius 
or  other  bone),  to  replace  bone  destroyed  by  injury  or  disease  (e.g., 
osteomyelitis,  syphilis,  tuberculosis,  neoplasms),  to  immobihze 
broken  bones  or  to  induce  ununited  fractures  to  consolidate,  and  to 
secure  rigidity  of  joints  which  are  too  mobile  because  of  paralysis, 
or  which  are  diseased,  e.g.,  bone  grafting  for  tuberculosis  of  the  spine 
(Albee's  operation).  It  has  been  stated  that  an  osseous  graft 
always  perishes  and  is  absorbed,  being  replaced  by  new  bone  derived 
from  the  periosteum;  from  the  osteoblasts  in  the  bone,  the  perios- 
teum acting  merely  as  a  Hmiting  membrane ;  or  from  the  li\dng  bone 
with  which  the  graft  is  brought  in  contact,  the  graft  possessing  not 
osteogenetic,  but  simply  osteoconductive  functions.  In  view  of  the 
fact  that  periosteum  without  bone,  bone  without  periosteum,  and 
isolated  fragments  of  either  or  both  may  persist  and  grow,  perhaps 
we  may  conclude  that  a  bone  graft  does  not  always  succumb,  and 
that  new  osseous  tissue  can  be  formed  from  the  osteoblasts  of  the 
deeper  layer  of  periosteum  or  from  those  of  the  bone  itself.  It 
seems,  however,  that  a  bone  graft  with  its  periosteum  is  twice  as 
likely  to  survive  as  one  without  that  membrane,  probably  because  of 
the  greater  number  of  blood  vessels  in  the  periosteum.  For  a  similar 
reason  OUier  emphasized  the  importance  of  the  medulla  in  preserving 
the  life  of  a  graft.  McWilliams  found  that  if  a  section  of  a  bone  is 
removed  subperiosteally,  the  bone  regenerates  between  the  frag- 
ments; that  without  a  periosteal  or  bony  bridge  there  is  very  little 
attempt  at  repair ;  that  small  fragments  of  a  bone  shorn  of  periosteum 
are  more  apt  to  five  than  large  ones,  because  the  blood  has  easier 
access  to  the  smaller  fragments;  and  that  periosteum  alone  when 
transferred  to  soft  parts  may  create  new  bone.  In  performing  bone 
transplantation  strict  asepsis,  rigorous  hemostasis,  and  gentle 
handUng  of  the  graft  are  essential.  No  attempt  should  be  made  to 
fill  a  septic  cavity  with  a  bone  graft.  Because  of  the  cytolytic  effect 
of  the  blood  and  the  body  fluids  on  alien  cells,  autoplastic  grafts, 

29 


450  MANUAL    OF    SURGERY 

i.e.,  from  the  same  individual,  are  the  most  successful.  If  a  homo- 
plastic graft,  i.e.,  one  from  another  individual,  must  be  employed 
one  of  the  same  blood  group  should  be  selected,  and  a  Wassermann 
test  made  to  exclude  syphilis.  Some  surgeons  have  taken  advantage 
of  the  opportunity  offered  to  obtain  bone  from  a  freshly  amputated 
limb  which  has  neither  been  infected  or  the  seat  of  a  malignant 
neoplasm,  e.g.,  a  limb  amputated  for  injury  or  dry  gangrene,  or  from 
an  individual  immediately  after  death  from  an  injury.  Heteroplas- 
tic grafts,  i.e.,  from  the  lower  animals,  generally  become  necrotic  or 
are  absorbed,  although  a  few  successful  transplantations  from  the 
dog,  the  lamb,  and  the  ape  (which  as  man's  nearest  animal  relative  is 
to  be  preferred)  have  been  reported.  When  sutures  are  needed  to 
fix  the  graft  in  place,  chromicized  catgut  or  kangaroo  tendon  is  the 
best  material  to  employ,  as  wire,  nails,  and  other  non-absorbable 
substances  predispose  to  suppuration  and  sinus  formation.  When- 
ever possible  incisions  should  be  made  in  such  a  way  that  the  suture 
line  in  the  skin  shall  not  lie  immediately  over  the  graft.  After  trans- 
plantation the  part  must,  according  to  the  size  and  situation  of  the 
graft,  be  immobilized  for  from  several  weeks  to  several  months. 

The  methods  of  bone  transplantation  may  be  divided  into  two 
groups,  viz.,  transplantation  by  flaps  and  free  transplantation. 

Transplantation  by  flaps  is  illustrated  by  the  various  osteoplastic 
resections  and  amputations  (see  Figs.  580,  581,  585,  and  585  to  588) 
A  periosteal  flap  with  a  thin  slice  of  bone  attached  can  be  raised  from 
the  bone  on  one  side  of  an  osseous  defect,  and  turned  over  so  as  to 
bridge  the  defect  (Oilier).  Flaps  oj  muscle  have  been  employed  to 
swing  a  piece  of  the  ihac  crest  into  the  femur,  a  piece  of  the  scapula 
into  the  humerus  (Codivilla) .  Flaps  of  skin  have  been  utilized  in  a 
similar  way,  thus  we  have  transplanted  a  metatarsal  bone  to  the 
tibia,  and  in  a  case  in  which  the  lower  ends  of  the  bones  of  the  fore- 
arm had  been  destroyed,  a  fragment  of  the  ulna  to  the  radius.  Bone 
may  be  grafted  also  one  end  at  a  time.  Huntington  closed  a  defect 
in  the  tibia  by  severing  the  fibula  at  its  upper  end  and  placing  it  in 
contact  with  the  upper  end  of  the  tibia.  After  union  had  occurred 
the  lower  end  of  the  fibula  was  transferred  to  the  lower  end  of  the 
tibia.  Subsequent  to  this  operation  the  fibula  thickens  in  response 
to  the  demand  made  upon  it.  Morton,  in  a  similar  case,  united  the 
lower  ends  of  the  bones  of  a  dog's  leg  to  the  upper  end  of  the  tibia, 
and  five  weeks  later  amputated  the  dog's  leg  and  placed  the  bones  in 
contact  with  the  astragalus.     A  useful  leg  resulted. 

In  free  transplantation  the  grafts  are  usually  taken  from  the  tibia, 
fibula,  clavicle,  scapula,  rib,  upper  third  of  the  ulna,  or  crest  of  the 


BONES  451 

ilium.  Periosteum  with  a  thin  slice  ot  osseous  tissue  may  be  used  to 
envelop  the  ends  of  a  broken  bone  that  have  been  joined  by  wire  or 
other  means  (Codivilla).  Small  bone  chips  have  been  employed  by 
Macewen  to  fill  defects  in  the  bones  of  the  extremity,  by  Keen  to  close 
gaps  in  the  skull.  With  rongeur  forceps  or  chisel  the  excised  frag- 
ment is  broken  into  small  pieces,  which  are  placed  in  the  cavity  to  be 
filled..  The  wound  is  closed  without  drainage.  A  large  section  may 
be  cut  from  a  bone  with  a  chisel,  or  an  electric  saw,  and  transferred 
quickly,  without  washing  in  salt  solution,  to  its  new  habitat,  where  it 
may  be  fixed  with  chromacized  catgut  sutures,  or  bone  pegs.  If  a 
chisel  is  employed  one  must  proceed  cautiously  and  with  Hght  blows, 
so  as  not  to  splinter  or  fragment  the  graft.  This  form  of  grafting  is 
employed  in  the  Albee  operation  for  tuberculosis  of  the  spine,  and  is 
rapidly  displacing  other  methods  in  the  operative  treatment  of 
fractures  (q.v.).  Transplantation  of  joints  is  mentioned  under 
ankylosis,  implantation  of  dead  bone  and  other  foreign  substances 
under  necrosis  and  the  operative  treatment  of  fractures.  In  the 
sections  on  regional  surgery  also  reference  is  made  to  bone  trans- 
plantation, when  the  particular  condition  may  be  so  treated. 

Transplantation  of  cartilage  is  more  apt  to  be  successful  when  the 
cartilage  is  accompanied  by  its  perichondrium.  Pieces  of  the  costal 
cartilages  have  been  used  to  fill  defects  in  the  face,  to  establish  new 
joints,  to  supply  the  place  of  absent  phalanges.  Transplantation  of 
an  articular  cartilage  with  its  attached  bone  (fibula)  likewise  has  been 
performed.  Whether  or  not  a  transplanted  epiphysis  can  participate 
in  the  growth  of  a  Hmb  is  a  question  that  is  still  unanswered.  Kutt- 
ner,  however,  one  year  and  eight  months  after  transplanting  the 
fibula  of  an  ape  to  the  leg  of  a  child,  in  whom  the  fibula  was  con- 
genitally  absent,  found  by  X-ray  examination  that  the  epiphyseal 
line  was  fully  preserved. 


CHAPTER  XX 


JOINTS 
INJURIES  OF  JOINTS 

Woiinds  of  joints  should  always  be  regarded  with  apprehension. 
Extensive  wounds  are  often  associated  with  dislocation  or  compound 
fracture.  A  small  penetrating  wound  may  be  recognized  by  the 
escape  of  synovial  fluid,  although  this  may  not  occur  if  the  aperture 
is  valvular  or  very  narrow,  and  synovia  may  escape  from  injured 
bursa.  A  probe  should  not  be  ernployed.  The  external  parts 
should  be  disinfected,  the  entire  wound  excised  and,  if  no  foreign 

body  remains  in  the  joint,  closed 
with  the  usual  technic  of  primary 
suture.  The  joint  should  be  im- 
mobilized with  a  splint  in  a  position 
which  will  give  the  best  function  in 
the  event  of  ankylosis.  At  the  first 
symptoms  of  infection,  viz.,  pain, 
swelling,  fever,  etc.,  the  wound 
should  be  reopened  and  if  it  is  not  so 
placed  as  to  provide  adequate  drain- 
age new  incisions  should  be  made; 
the  pus  washed  from  the  joint  cavity  with  a  weak  antiseptic  solution, 
preferably  Dakin's,  and  drainage  instituted.  Military  experience 
has  shown  drainage  material  must  not  be  introduced  within  the 
synovial  cavity,  gauze  should  never  be  employed.  Infected  joints 
can  be  sterilized  with  the  chlorine  antiseptics  and  delayed  primary 
and  secondary  suture  practiced.  Willems  insists  upon  the  active 
movement  of  open  suppurating  joints  to  facilitate  the  drainage  of 
the  purulent  discharge  and  prevent  the  formation  of  adhesions. 
It  has  been  most  successful  in  the  large  joints  as  the  knee  and 
shoulder.  If  the  joint  is  wounded  by  an  instrument  which  is  known 
to  be  grossly  infected,  one  should  not  wait  for  the  appearance  of  septic 
symptoms,  but  open,  disinfect,  and  drain  the  joint  at  once. 
Resection  or  amputation  may  be  necessary  if  severe  constitutional 
s3''mptoms  continue. 

A  sprain  has  been  defined  as  a  self-reduced  dislocation.  As  the 
result  of  a  twist,  some  fibers  of  the  hgaments  are  stretched  or  lac- 

452 


Pig.    231. — Strapping  of  the  ankle. 


JOINTS  453 

eratcd  ami  ihc  sNiioxial  nu'inljianc  contused.  The  symptoms  are 
severe  pain,  tenderness,  swelling  of  the  joint  from  effusion  of  blood 
and  lymph,  loss  of  function,  and  in  some  instances  shock.  Many 
cases  of  fractures  about  joints  have  in  the  past  been  diagnosticated 
as  sprains.  If  the  swelling  is  great,  fracture  can  be  excluded  only  by 
the  X-ray. 

The  treatment  during  the  lirst  twenty-four  hours  is  elastic  com- 
pression, and  cold  in  the  form  of  an  ice  bag  or  evaporating  lotion, 
thus  limiting  effusion.  Compression  is  best  made  with  a  firm  band- 
age over  a  layer  of  cotton.  If  the  effusion  is  excessive,  aspiration 
should  be  considered.  Later  absorption  should  be  promoted  by 
heat  and  massage.  The  joint  should  be  kept  at  rest  until  the  pain 
and  swelling  have  disappeared.  Compression  with  a  certain  degree  of 
fixation  may  be  obtained  by  applying  overlapping  strips  of  adhesive 
plaster  around  the  joint  as  shown  in  Fig.  231,  Subsequent  stiffness 
may  be  relieved  by  the  hot  air  treatment  and  by  frictions  with 
stimulating  liniments.  The  prognosis  is  good  in  uncomplicated 
cases;  suppuration  is  rare,  although  tuberculosis  may  occur  in  those 
prone  to  this  disease,  and  persistent  pain  and  stiffness  are  common  in 
the  gouty  and  rheumatic  and  in  the  old.  Absorption  of  the  head  of 
the  femur  may  occur  after  sprain  of  the  hip.  Ankylosis  is  the  chief 
danger. 

DISLOCATIONS 

A  dislocation,  or  luxation,  is  an  abnormal  displacement  of  the 
articular  end  of  a  bone.  Dislocations  may  be  congenital  or  ac- 
quired, and  the  latter  may  be  traumatic  or  spontaneous  (patholog- 
ical) . 

Congenital  dislocations  are  usually  due  to'defective  development, 
although  it  is  possible  that  a  few  are  due  to  violence  to  the  mother's 
abdomen  during  pregnancy,  or  to  a  vicious  position  of  the  child  in 
the  uterus,  the  result  of  tumors,  etc.  Although  various  joints  may 
be  affected  in  this  way,  in  90  per  cent,  of  the  cases  the  hip  is  involved. 

Congenital  dislocation  of  the  hip  is  more  frequent  in  females,  both 
or  more  commonly  one  joint  being  involved.  Damany  states  that 
the  luxation  rarely  exists  at  the  time  of  birth,  but  occurs  during  the 
first  year  of  Ufe,  owing  to  an  increased  forward  obliquity  of  the 
acetabulum  and  an  exaggeration  of  the  normal  torsion  of  the  femur, 
thus  causing  a  progressive  displacement  of  the  head  of  the  femur 
when  the  thighs  are  extended.  However  this  may  be,  congenital 
dislocation  of  the  hip  is  seldom  recognized  until  the  child  begins  to 
walk.     The  dislocation  causes  atrophy  of  the  abandoned  acetabu- 


454 


MLA.NUAL    OF    SURGERY 


lum,  Stretching  or  rupture  of  the  round  ligament,  shortening  and 
anteversion  of  the  neck  of  the  femur,  flattening  of  the  head  of  the 
bone  from  before  backwards,  and  elongation  with  occasionally 
hour-glass  constriction  of  the  capsule  of  the  joint.  The  limb  is 
atrophied  and  the  muscles  altered  in  length.  The  head  of  the  bone 
almost  invariably  passes  onto  the  dorsum  of  the  ilium,  thus  causing 
shortening  with  flexion  and  adduction  of  the  thigh,  compensatory 
obliquity  of  the  pelvis,  and  anterior  curvature  of  the  lumbar  spine 
(Fig.   232).     In  bilateral  dislocation  there  is  a  peculiar  waddling 

gait,  in  unilateral  cases  there  is  limping 
and  associated  scoliosis.  In  early  cases 
the  length  of  the  limb  may  be  restored  by 
traction. 

The  treatment,  when  the  condition  is 
recognized  before  the  child  begins  to  walk 
and  before  marked  changes  in  the  soft  struc- 
tures occur,  is  continuous  traction  on  the 
limb  to  bring  the  head  of  the  bone  down 
to  the  acetabulum,  while  the  limb  is  fixed 
in  abduction  and  pressure  is  made  over 
the  great  trochanter.  This  treatment 
must  be  continued  for  six  months  or  a 
year.  At  a  later  period,  up  to  four  or  five 
years  in  bilateral  cases  and  about  seven 
years  in  unilateral  cases,  the  Lorenz  blood- 
less method  may  be  tried.  The  author  of 
this  method  claims  50  per  cent,  anatomic 
cures.  Under  anesthesia  the  shortened 
muscles  are  stretched  by  flexion,  extension, 
and  abduction  of  the  thigh,  during  the  last 
of  which  the  adductor  muscles  are  power- 
fully kneaded.  The  head  of  the  bone  is 
then  drawn  down  to  the  level  of  the  acetabulum  by  traction  on  the 
leg.  and  the  thigh  flexed  on  the  abdomen,  rotated  internally,  abducted, 
and  finally  rotated  outwards  while  pressure  is  made  on  the  trochanter. 
With  the  hmb  in  flexion,  abduction,  and  eversion,  a  plaster-of-Paris 
cast  is  applied  to  the  pelvis  and  thigh  as  far  as  the  knee.  The 
child  is  allowed  to  walk  \^'ith  the  limb  in  this  position  in  order  to 
deepen  the  acetabulum.  At  the  end  of  three  months  the  cast  is  re- 
moved, the  flexion  and  abduction  lessened,  and  another  cast  put  on 
for  three  more  months. 

In  children  too  old  for  the  bloodless  method  Hoft'a  and  Lorenz 


Fig.  232. — Bilateral  congenital 
dislocation  of  hip.     (Hopkins.) 


JOINTS  455 

have  each  devised  a  bloody  method.  The  former  opens  the  joint  by  an 
incision  similar  to  that  of  Langenbeck  in  resection  of  the  hip,  severs 
shortened  iibers  of  muscle  and  fascia,  enlarges  the  acetabulum  with  a 
gouge,  reduces  the  dislocation,  fixes  the  limb  in  eversion  and  abduc- 
tion for  a  few  weeks,  and  linally  straightens  the  limb.  Lorenz  opens 
the  joint  from  in  front,  does  not  cut  the  muscles,  but  severs  the  ham- 
strings if  necessary.  The  rest  of  the  operation  is  much  the  same 
as  that  of  Hoffa. 

Pathological  dislocations  occur  from  shght  force  or  spontaneously, 
as  the  result  of  disease,  such  as  tuberculosis,  osteoarthritis,  Charcot's 
disease,  and  unopposed  action  of  muscles  in  paralysis.  Those 
occurring  in  the  course  of  fevers  (Fig.  233)  are  due  to  distention  of 
the  joint,  and  are  most  frequent  at  the  hip,  owing  to  habitual  flexion 
of  the  thighs  in  bed. 


Fig.   233. — Dislocation  of  hip  in  typhoid  fever,  and  large  bed  sore.     (Pennsylvania 

Hospital.) 

Traumatic  dislocations,  like  fractures,  may  be  simple  (closed), 
compound  [open),  complete,  incomplete  [subluxation) ,  or  complicated 
(associated  with  injury  of  the  soft  parts,  vessels,  nerves,  or  viscera). 
K  fracture-dislocation  is  one  associated  with  a  fracture  entering  the 
joint  (Fig.  219). 

The  causes  of  traumatic  dislocations  are  predisposing  and  excit- 
ing. The  predisposing  causes  are  powerful  muscular  development, 
thus  dislocations  are  more  frequent  in  males  and  in  middle  life; 
occupations  which  demand  hard  labor  and  exposure  to  injury; 
structure  and  situation  of  the  joint,  e.g.,  the  shoulder,  which  is  a  ball 
and  socket  joint  and  exposed  to  many  injuries;  and  diseases  or  pre- 
vious injuries  of  joints  which  relax  the  ligaments  or  markedly  alter 
the  axis  of  the  hmb.  The  exciting  causes  are  external  violence 
(direct,  or  more  commonly,  indirect)  and  muscular  action. 

The  pathology  consists  of  a  tearing  of  the  ligaments  and  fre- 


456  MANUAL   OF    SURGERY 

quently  of  the  soft  structures  around  the  joint,  owing  to  the  displace- 
ment of  the  articulating  surfaces;  effusion  of  blood  into  and  about  the 
joint;  contusion  of  the  synovial  membrane  and  articular  cartilages; 
and  occasionally  fracture,  or  compression  or  rupture  of  important 
nerves,  vessels,  or  viscera.  If  the  dislocation  is  reduced,  the  subse- 
quent traumatic  inflammation  subsides  with  or  without  adhesions. 
If  the  torn  ligaments  are  not  fully  repaired,  there  is  a  predisposition 
to  the  recurrence  of  the  dislocation.  In  an  unreduced  dislocation 
the  organization  of  the  effused  blood  and  exudate  fills  the  normal 
articular  cavity  with  fibrous  tissue  and  fixes  the  head  in  its  new 
situation,  where,  if  persistent  movements  are  made,  it  may  form  a 
pseudoarthrosis.  The  displaced  head  becomes  more  or  less  deformed, 
and  wears  a  hollow  in  the  bone  on  which  it  rests.  The  surrounding 
muscles  atrophy,  and  are  altered  in  length  to  accommodate  them- 
selves to  the  new  position  of  the  limb. 

The  symptoms  are  pain,  swelling,  ecchymosis,  rigidity  of  the 
muscles,  loss  of  function,  and  deformity,  as  evidenced 
by  the  alteration  in  the  axis  and  length  of  the  limb, 
by  the  disturbed  relations  of  the  bony  prominences 
about  the  joint,  and  by  feehng  or  seeing,  with  or  with- 
FiG.  234.        out  the  X-ray,  the  empty  articular  cavity  and  the 

Clove-hitch.  ]•      i  11  •      •-  •.        .• 

displaced  bone  m  its  new  situation. 
The  treatment  is  (i)  reduction,  (2)  retention,  (3)  restoration  of 
function,  (i)  Reduction  should  be  made  at  the  earliest  possible 
period  by  manipulation  or  extension,  with  or  without  anesthesia 
according  to  the  difficulties  encountered.  Manipulation  consists  in 
such  movements  of  the  limb  as  will  cause  the  dislocated  bone  to 
reenter  the  joint  by  the  path  through  the  torn  capsule  which  it  has 
already  traversed,  hence  it  should  be  employed  whenever  possible, 
because  but  little  additional  injury  is  inflicted  upon  the  tissues. 
Extension,  or  more  commonly  extension  and  counterextension,  are 
used  to  draw  the  dislocated  bone  into  place  despite  the  resistance  of 
muscles  and  other  structures.  Extension  is  made  by  the  hands  of  the 
surgeon,  by  a  broad  band  fastened  about  the  extremity  in  a  clove-, 
hitch  (Fig.  234)  and  passed  around  the  waist  or  shoulders  of  the 
surgeon,  or,  much  more  rarely,  by  compound  pulleys.  Counter- 
extension  is  obtained  by  the  hands  of  an  assistant,  by  a  broad  band 
or  by  the  knee  or  the  foot  of  the  surgeon.  The  application  of  great 
force,  however,  is  very  dangerous,  and  if  sufficient  relaxation  cannot 
be  obtained  with  ether,  reduction  through  an  incision  should  be 
employed.  The  bone  usually  goes  back  into  place  with  an  audible 
snap.     (2)  After  reduction  the  joint  is  immobilized  until  the  lacera- 


JOIN.TS  457 

tion  in  the  capsule  has  healed,  ij,)  Duriiiji;  the  I'lrst  twenty-four 
hours  compression  with  a  bandage  and  the  api)Hcation  of  evaporating 
lotions  or  an  ice  bag  serve  to  limit  the  swelling.  Subsequently 
absorption  is  hastened  by  massage,  heat,  and  liniments,  and  at  the 
end  of  from  ten  days  to  two  weeks  passive  motions  are  begun. 

Compound  dislocations  are  very  grave  injuries,  w^hich  require 
the  same  care  as  compound  fractures  (page  384).  The  supervention 
of  sepsis  may  necessitate  resection  or  amputation.  The  treatment 
of  fracture  near  a  dislocated  joint  has  already  been  discussed. 

Old  tinreduced  dislocations  are  difficult  to  treat  owing  to  the  firm 
adhesions  which  anchor  the  bone  in  its  new  position.  There  is  no 
fixed  rule  as  to  the  time  when  reduction  should  no  longer  be  at- 
tempted, as  replacement  may  be  effected  sometimes  after  a  number 
of  months  have  elapsed.  A  general  rule  is  to  attempt  reduction 
under  anesthesia  without  the  use  of  too  great  force,  as  such  may 
seriously  injure  important  vessels  or  nerves,  or  result  in  fracture; 
if  reduction  is  not  successful  and  the  limb  is  incapacitated  by  pain 
or  marked  limitation  of  motion,  the  joint  should  be  opened  and  the 
bone  replaced,  or  in  some  cases  the  head  of  the  bone  excised.  In 
joints  in  which  bloodless  reduction  has  not  been  successful,  but  in 
which  there  is  fair  motion  and  little  or  no  pain,  operation  should  not 
be  undertaken,  since  persistent  movements  may  result  in  a  fairly 
useful  pseudoarthrosis. 

SPECIAL  DISLOCATIONS 

The  lower  jaw  may  be  dislocated  upwards,  the  condyle  entering 
the  cranial  cavity,  or  backwards;  but  these  are  extremely  rare  and 
the  usual  displacement  is  forwards,  either  one  or  much  more  com- 
monly both  sides  being  affected.  The  condyles  pass  forward  over 
the  eminentia  articularis  into  the  zygomatic  fossa,  as  the  result  of 
blows  on  the  chin,  or  contraction  of  the  external  pterygoids  when  the 
mouth  is  opened  in  yawning,  vomiting,  trying  to  take  a  big  bite,  etc. 

The  symptoms  are  an  open  mouth  which  cannot  be  closed,  pro- 
jection of  the  low^er  jaw  forwards,  drooling  of  saliva,  and  some  inter- 
ference wdth  speech  and  swallowing.  The  condyles  may  be  felt 
anteriorly  and  there  is  an  abnormal  depression  in  front  of  the  tragus. 
In  the  unilateral  variety  the  symptoms  are  less  pronounced  and  the 
chin  passes  towards  the  sound  side.- 

The  treatment  is  pressure  downw^ards  and  backwards  on  the  last 
lower  molar  teeth  with  the  thumbs,  protected  by  bandages,  while 
the  chin  is  elevated  with  the  fingers.     The  mouth  should  be  kept  shut 


458  MANUAL   OF    SURGERY 

by  a  Barton  bandage  for  two  weeks,  after  which  the  patient  should 
be  cautioned  against  opening  the  mouth  too  widely.  In  old  cases 
excision  of  the  condyle  may  be  indicated. 

The  sternal  end  of  the  clavicle  may  be  dislocated  forward,  back- 
ward, or  upward. 

Forward  dislocation  is  caused  by  violence  which  pushes  or  pulls 
the  shoulder  backwards.  The  end  of  the  bone  is  in  front  of  the 
sternum,  the  acromion  process  nearer  the  middle  line,  and  the 
clavicular  head  of  the  sternomastoid  unduly  prominent.  Reduction 
is  effected  by  pulling  the  shoulders  backwards  while  the  knee  is 
placed  between  the  scapulae  and  pressure  is  made  upon  the  displaced 
bone.  A  pad  is  fixed  over  the  joint  by  adhesive  plaster  and  the 
shoulders  are  pulled  backwards  by  a  posterior  figure-of-8  bandage; 
recumbency  is  a  great  aid  to  the  maintenance  of  reduction.  The 
dressing  should  be  worn  for  one  month,  and  even  then  some  degree 
of  displacement  is  likely  to  remain. 

Backward  dislocation  is  rare,  and  is  caused  by  direct  violence, 
or  by  a  forcing  of  the  shoulder  forwards  and  inwards.  The  head  of 
the  bone  lies  behind  the  sternum,  a  depression  exists  over  the  joint, 
the  acromion  is  nearer  the  middle  line,  movements  of  the  head  and 
neck  are  painful  or  impossible,  and  occasionally  there  are  dyspnea, 
dysphagia,  or  congestion  of  the  head,  from  pressure  upon  the  trachea, 
esophagus,  or  blood  vessels.  Reduction  and  treatment  are  the 
same  as  those  for  forward  dislocation,  except  that  pressure  is  not 
made  on  the  head  of  the  displaced  bone.  If  reduction  cannot  be 
promptly  made  in  cases  with  serious  pressure  symptoms,  the  head  of 
the  bone  may  be  excised,  or  wired  in  place. 

Upward  dislocation  is  very  rare,  and  is  caused  by  violent  depres- 
sion of  the  shoulder.  The  head  of  the  bone  may  be  felt  in  its  new 
situation,  where  it  may  press  upon  the  esophagus  or  trachea.  The 
shoulder  falls  downwards  and  inwards.  The  bone  is  replaced  by 
pressing  the  elbow  inwards  over  a  pad  in  the  axilla,  while  downward 
pressure  is  made  on  the  head  of  the  bone.  The  limb  is  bandaged  to 
the  side  in  this  position  for  several  weeks. 

The  acromial  end  of  the  clavicle  may  be  dislocated  downwards, 
but  the  usual  displacement  is  upwards.  The  cause  is  violence  to  the 
shoulder.  In  dislocation  upwards  the  outer  end  of  the  clavicle  is 
prominent,  the  shoulder  passes  downwards  and  inwards,  and  its 
movements  are  limited.  Dislocation  downwards  causes  a  depression 
over  the  joint  and  a  prominence  of  the  acromion.  The  shoulders 
should  be  pulled  backwards,  and  pressure  made  upon  the  outer  end 
of  the  clavicle  or  upon  the  acromion  according  to  the  displacement. 


JOINTS  459 

A  bandage  or  adhesive  strap  is  then  passed  over  the  shoulder  and 
under  the  elbow,  and  held  in  place  by  a  band  passing  around  the 
chest.  Some  deformity  is  very  apt  to  persist,  and  in  bad  cases 
suturing  of  the  bones  with  silver  wire  or  kangaroo  tendon  should  be 
considered. 

Dislocation  of  the  lower  end  of  the  scapula  (sec  scapulum  alatum) . 

Dislocation  of  the  shoulder  is  the  most  frequent  of  all  dislocations, 
owing  to  the  exposed  position  and  great  mobility  of  the  joint,  and 
the  disproportion  between  the  head  of  the  humerus  and  the  depth 
of  the  glenoid  cavity.  A  fall  upon  the  outstretched  hand  or  elbow 
is  the  usual  cause.  As  a  rule  the  head  of  the  bone  is  forced  through 
the  weakest  portion  of  the  capsule,  i.e.,  the  lower  and  inner  part, 
into  the  axilla;  it  remains  in  this  situation  (subglenoid) ,  or,  as  the 
result  of  muscular  action  or  the  direction  of  the  force,  passes  back- 
wards and  downwards  beneath  the  spine  of  the  scapula  (subspinous) , 
forwards  and  upwards  beneath  the  clavicle  (subclavicular) ,  or  most 
commonly  three-fourths  of  all  the  cases)  forwards  and  downwards 
beneath  the  coracoid  process  (subcoracoid) .  The  subclavicular, 
subcoracoid,  and  subspinous  dislocations  may,,  however,  be  primary, 
i.e.,  the  head  of  the  bone  may  pass  directly  to  its  new  situation  with- 
out first  entering  the  axilla.  Two  other  forms,  which  are  very  rare, 
may  be  mentioned,  viz.,  the  supracoracoid,  in  which  the  head  of  the 
humerus  passes  above  the  coracoid  and  usually  fractures  it  or  the 
acromion  process,  and  luxatio  erecta,  in  which  the  head  of  the  bone 
lies  in  the  axilla,  but  the  humerus  projects  upwards  against  the  head 
of  the  patient. 

The  symptoms  of  all  varieties  of  dislocation  of  the  shoulder  except 
luxatio  erecta  are  (i)  pain,  swelling,  rigidity,  ecchymosis,  and  loss  of 
function;  (2)  flattening  of  the  shoulder  and  prominence  of  the  acro- 
mion process  (Fig.  235),  so  that  a  ruler  can  be  made  to  touch  the 
acromion  process  and  the  external  condyle  at  the  same  time;  (3) 
a  hard  swelling  in  the  situation  abnormally  occupied  by  the  head  of 
the  bone;  (4)  Dugas'  sign,  i.e.,  projection  of  the  elbow  from  the  side 
when  the  hand  is  on  the  opposite  shoulder,  and  inability  to  place  the 
hand  on  the  opposite  shoulder  when  the  elbow  is  forced  against  the  side 
(this  may  be  absent  in  some  subcoracoid  dislocations) ;  (5)  increase  in 
the  vertical  measurement  around  the  axilla  (Callaway's  sign)  with 
lowering  of  one  of  the  axillary  folds  (Bryant's  sign) ;  and  (6)  dis- 
placement as  shown  by  the  X-ray.  The  variety  of  dislocation  may 
be  diagnosticated  by  the  situation  of  the  head  of  the  bone;  by  the 
axis  of  the  limb,  the  elbow  projecting  from  the  side  in  all  instances, 
but    decidedly    backwards    in    the   subcoracoid   and   subclavicular 


460 


MANUAL    OF    SURGERY 


forms,  slightly  backwards  in  the  subglenoid,  and  forwards  in  the 
subspinous;  by  the  length  of  the  Hmb,  which  is  lessened  in  the  sub- 
clavicular, increased  very  little  if  at  all  in  the  subcoracoid,  slightly 
increased  in  the  subspinous,  and  decidedly  increased  in  the  sub- 
glenoid; and  by  the  X-ray.  Rupture  or  compression  of  the  axillary 
vessels  or  brachial  plexus  may  occur.  Subluxation  of  the  shoulder 
is  a  condition  in  which  the  head  of  the  bone  passes  forwards,  owing 
to  rupture  or  displacement  of  the  long  head  of  the  biceps. 

The  treatment  is  reduction  by  manipulation  or  extension,  employ- 
ing ether  if    much  difficulty  is  encountered.     Kocher's  method   is 


Fig.  235. — Subcoracoid  dislocation  of  the  shoulder. 

useful  in  forward  dislocations.  The  elbow  is  flexed  to  a  right  angle 
and  pressed  to  the  side.  External  rotation  is  then  performed  by 
abducting  the  forearm  until  it  is  at  a  right  angle  with  the  sagital  plane 
of  the  body.  If  this  does  not  cause  reduction,  the  elbow  is  drawn 
forwards  until  the  arm  is  at  a  right  angle  with  the  coronal  plane  of 
the  body,  and  internal  rotation  performed  by  placing  the  hand  on 
the  sound  shoulder  and  the  elbow  in  contact  with  the  chest.  Ex- 
ternal rotation  relaxes  the  posterior  untorn  portion  of  the  capsule, 
which  lies  across  the  glenoid  cavity,  and  causes  the  opening  in  the 
capsule  to  gap.  When  the  elbow  is  carried  forward,  the  capsule 
above  the  rent  is  relaxed,  and  the  lower  margin  of  the  opening  acts 
as  a  taut  band  which  directs  the  head  of  the  bone  into  the  glenoid 


JOINTS  461 

cavity.  The  method  should  not  be  used  if  there  is  great  resistance 
to  external  rotation,  as  in  such  instances  the  neck  of  the  bone  may  be 
broken.  In  Smith's  method,  for  anterior  dislocation,  the  surgeon 
stands  in  front  of  the  patient  and,  if  the  left  humerus  is  dislocated 
grasps  the  shoulder  with  his  left  hand,  the  fingers  resting  on  the 
scapula  and  the  thumb  on  the  head  of  the  bone.  With  the  right 
hand  the  elbow  is  abducted  to  a  right  angle,  extended,  everted,  and 
carried  towards  the  sternum  while  pressure  is  made  on  the  head  of 
the  bone.  For  the  right  shoulder  the  position  of  the  surgeon's 
hands  is  reversed.  In  subspinous  dislocation  the  surgeon  stands 
behind  the  patient  and  in  a  similar  manner  abducts  and  extends  the 
arm;  external  rotation  is  then  performed,  and  the  elbow  carried 
towards  the  spine  while  the  thumb  presses  the  bone  forwards  into 
the  glenoid  cavity.  In  reduction  by  extension  the  patient  Hes 
down,  and  the  arm  is  pulled  directly  outwards  while  counterextension 
is  made  by  placing  the  unshoed  foot  against  the  chest  close  to  the 
head  of  the  bone.  If  this  fails,  the  arm  is  carried  downwards  while 
the  foot  is  used  as  a  fulcrum  to  drive  the  head  of  the  bone  into 
place.  Some  surgeons  make  the  extension  downwards,  others  place 
the  foot  over  the  acromion  and  pull  the  arm  above  the  head.  Cooper's 
method  consists  in  placing  the  knee  in  the  axilla  of  a  sitting  patient 
and  forcing  the  elbow  to  the  side.  In  all  methods  of  extension,  and 
particularly  in  the  vertical  form,  there  is  danger  of  injury  to  the 
axillary  nerves  or  vessels.  After  reduction  the  joint  should  be 
immobilized  for  a  week  or  ten  days  by  a  Velpeau  bandage. 

Recurrent  dislocation  of  the  shoulder  is  due  to  relaxation  of  the 
capsule  as  the  result  of  nonunion  of  the  laceration  in  it  or  stretching 
of  the  cicatrix.  The  shoulder  may  be  strengthened  by  electricity, 
massage,  and  a  support,  or,  after  making  an  incision  similar  to  that 
recommended  for  excision  of  the  joint  the  gap  in  the  capsule  may  be 
sutured  or  the  capsule  reefed.  We  have  employed  Thomas's  incision 
for  capsulorrhaphy.  The  incision  is  made  in  the  axilla,  along  the 
anterior  border  of  the  coraco-bracialis,  which  with  the  biceps  and 
pectoralis  major  is  retracted  outwards,  the  axillary  vessels  and  nerves, 
including  the  musculo-cutaneous  nerve  being  drawn  inwards.  The 
anterior  circumflex  vessels  are  ligated  and  cut,  and  about  half  the 
width  of  the  subscapularis  divided,  care  being  taken  not  to  injure 
the  circumflex  nerve  or  the  posterior  circumflex  vessels.  The 
myeloplasty  of  Clairmont-Erlich  consists  in  wrapping  a  strip  of 
muscle,  taken  from  the  posterior  border  of  the  deltoid,  around  the 
inferior  part  of  the  capsule,  and  suturing  the  strip  to  the  anterior 
margin  of  the  deltoid. 


462 


MANUAL    OF    SURGEEY 


Dislocations  of  the  elbow  are  most  frequent  in  children,  and  are 
caused  by  direct  or  indirect  violence.  In  dislocation  of  both  bones 
of  the  forearm  the  displacement  may  be  backwards,  forwards,  or 
lateral. 

Dislocation  of  both  bones  backwards  is  the  most  frequent  variety. 
The  coronoid  process  lodges  in  the  olecranon  fossa,  the  forearm  being 
flexed,  midway  betw^een  pronation  and  supination,  and  shortened. 
Occasionally  the  coronoid  process  is  broken  (mobihty  and  crepitus) . 
The  lower  end  of  the  humerus  displaces  the  artery  and  soft  tissues 
forwards,  and  projects  at  or  below  the  crease  of  the  elbow;  the  upper 
ends  of  the  bones  of  the  forearm  form  a  projection  posteriorly,  and 
the  relations  between  the  olecranon,  head  of  the  radius,  and  condyles 


Fig.  236. — Old  backward  dislocation  of  the  elbow,  reduced  after  opening  the  joint. 

are  markedly  ajtered  (Fig.  236).  For  diagnosis  see  fractures  about 
the  elbow.  The  treatment  is  reduction  by  strong  traction,  and 
flexion  of  the  forearm  across  the  knee,  which  is  placed  in  the  bend  of 
the  elbow  while  the  patient  is  in  the  sitting  position  (Cooper's 
method) .  The  arm  is  placed  in  the  Jones  position  for  a  week  or  ten 
da3^s. 

Dislocation  of  both  bones  forwards  seldom  occurs  without  frac- 
ture of  the  olecranon.  The  forearm  is  lengthened  and  flexed  and  the 
normal  prominence  of  the  olecranon  is  absent.  The  treatment  is 
pressure  downwards  on  the  bones  of  the  forearm  by  the  knee  in  the 
bend  of  the  elbow,  the  forearm  being  drawn  upon  and  flexed  by  one 
hand,  while  the  other  makes  forward  traction  on  the  humerus.  The 
arm  is  then  dressed  in  the  Jones  position  for  a  week  or  ten  days. 


JOINTS  463 

Lateral  dislocation  of  both  bones,  cither  outwards  or  inwards  is 
infrequent  and  usually  incomplete.  In  either  instance  the  forearm 
is  flexed  and  fixed,  and  the  joint  widened;  the  form  of  displacement  is 
determined  by  studying  the  relations  of  the  bony  landmarks  about 
the  elbow.  Reduction  is  made  by  traction  on  the  forearm,  the 
upper  end  of  which  is  pushed  inwards  or  outwards  according  to  the 
form  of  dislocation.  The  arm  should  be  placed  in  the  Jones  position 
for  a  week  or  ten  days. 

Dislocation  of  the  ulna  alone  is  rare,  and  can  occur  only  in  a 
backward  direction;  the  forearm  is  flexed,  fixed,  and  pronated,  and 
the  olecranon  is  unduly  prominent.  The  treatment  is  the  same  as 
that  for  dislocation  of  both  bones  of  the  forearm  backwards. 

Dislocation  of  the  radius  alone  may  be  forwards,  backwards,  or 
outwards. 

Forward  dislocation  is  the  usual  variety;  it  results  from  a  fall  on 
the  hand  when  the  forearm  is  pronated  and  extended,  or  from  direct 
violence  to  the  posterior  part  of  the  joint.  The  forearm  is  midway 
betW'Cen  pronation  and  supination,  and  cannot  be  flexed  beyond  a 
right  angle,  as  the  head  of  the  bone  strikes  the  lower  end  of  the  hum- 
erus. The  head  can  be  felt  rotating  beneath  the  skin,  and  a  depres- 
sion is  noticed  posteriorly  beneath  the  external  condyle.  Reduction 
is  the  same  as  that  for  dislocation  of  both  bones  forwards.  The  arm 
should  be  kept  in  the  Jones  position  for  several  weeks,  as  deformity 
is  likely  to  recur  owing  to  rupture  of  the  orbicular  hgament. 

Backward  dislocation  is  rare,  and  is  caused  by  a  fall  on  the  hand, 
or  a  blow  on  the  head  of  the  bone  from  the  front.  The  forearm  is 
flexed,  fixed,  and  pronated,  and  the  head  of  the  bone  can  be  felt 
rotating  behind  the  external  condyle.  Reduction  is  the  same  as 
that  for  both  bones  backwards,  the  arm  being  fixed  in  the  Jones 
position  for  several  weeks,  although  recurrence  of  the  deformity  is 
not  as  menacing  to  the  function  of  the  elbow  as  in  the  preceding 
dislocation. 

Outward  dislocation  is  very  rare.  The  head  of  the  bone  may  be 
felt  external  to  the  outer  condyle;  it  is  reduced  by  extension  and 
direct  pressure,  and  the  forearm  is  dressed  in  flexion. 

Dislocation  of  the  radius  forwards  and  ulna  backwards  is 
exceedingly  rare,  and  causes  great  deformity  and  impairment  of 
function. 

Subluxation  of  the  head  of  the  radius  occurs  in  children  as  the 
result  of  a  forcible  pull  on  the  forearm.  The  head  of  the  bone  is 
displaced  downward  and  a  fold  of  the  orbicular  ligament  becomes 
pinched  in  the  joint.     The  forearm  is  flexed  pronated,  and  powerless, 


464 


MANUAL   OF    SURGERY 


../^ 


and  pain  and  tenderness,  increased  by  supination,  exist  over  the 
head  of  the  radius.  The  forearm  should  be  forcibly  supinated  and 
then  flexed,  and  the  elbow  immobilized  for  a  few  days. 

Dislocation  of  the  wrist  is  rare,  but  may  follow  a  fall  on  the  hand 
or  direct  violence.  The  displacement  may  be  backwards  or  for- 
wards; the  deformity  of  the  former  resembles  Colles'  fracture,  but 
the  styloid  processes  of  the  ulna  and  radius  project  beneath  the  skin 
on  the  flexor  side  of  the  wrist,  and  their  relations  to  each  other  are 
not  disturbed.  In  forward  dislocation  the  deformity  is  reversed. 
Reduction  is  effected  by  traction  on  the  hand  and  pressure  over 
the  deformity,  and  the  wrist  is  immobilized  on  a  Bond  splint  for 
two  weeks. 

Dislocation  of  the  lower  end  of  the  ulna  forwards,  or  more  com- 
monly backwards,  occasionally  occurs  in  twists  of  the  forearm;  the 
deformity  is  readily  detected,  and  easily  re- 
duced by  extension  and  pressure.  The  fore- 
arm and  hand  should  be  splinted  for  several 
weeks. 

Dislocation  of  the  carpal  bones  is  un- 
common apart  from  crushes.  It  is  possible 
for  the  second  row  of  bones  to  be  dislocated 
backward  or  forwards  from  the  first,  or  for 
any  one  of  the  carpal  bones  to  be  individually 
dislocated.  The  most  frequent  injury  is 
anterior  dislocation  of  the  semilunar,  a  sort 

Fig.     237. — Complete  ^^  r     ■, 

backward  dislocation  of  of  silver-fork  deformity  resulting,  owing  to 
thumb.    (Agnew.)  ^^^  prominence  of  the  os  magnum,  and  the 

depression  just  above  it  caused  by  the  forward  displacement  of  the 
semilunar,  which  is  felt  under  the  flexor  tendons  of  the  wrist.  The 
relations  between  the  styloid  processes  and  the  radius  are  unaltered, 
although  the  distance  from  the  radial  styloid  to  the  base  of  the  first 
metacarpal  is  lessened.  Reduction  may  be  effected  by  hyperexten- 
sion,  then  hyperflexion  over  the  thumbs  of  an  assistant,  which  press 
on  the  semilunar  (Codman  and  Chase).  Excision  of  any  of  the 
bones  may  be  demanded  in  irreducible  dislocations. 

Dislocations  of  the  metacarpal  bones,  i.e.,  at  the  carpo-meta- 
carpal  joint,  are  infrequent.  The  metacarpal  bone  of  the  thumb  is 
the  one  most  frequently  displaced,  the  cause  being  powerful  flexion 
or  direct  violence.  The  base  of  the  bone  forms  a  posterior  promi- 
nence, which  is  easily  reduced  but  hard  to  keep  in  place.  An 
adhesive  strap  should  be  put  over  the  joint,  and  the  thumb  fixed  in 
abduction  on  a  palmar  splint  for  two  weeks  or  longer. 


JOINTS 


465 


Dislocation  of  the  metacarpo-phalangeal  joints,  excepting  that  of 
the  thumb,  are  infrequent.  Forward  dislocations  are  readily  recog- 
nized and  easily  reduced.  Backward  dislocation  of  the  thumb  or  of 
any  of  the  lingers  is  often  dilllcult  to  reduce,  and  the  treatment  of  the 
former  will  serve  as  a  guide  for  that  of  the  latter.  There  are  three 
forms  of  backward  dislocation  of  the  thumb.  The  incomplete  some 
persons  are  able  to  produce  at  will  by  hyperextending  the  thumb  until 
it  forms  an  obtuse  or  even  a  right  angle  with  the  metacarpal  bone. 
The  complete  is  caused  by  forced  extension,  the  first  phalanx  project- 
ing backwards  at  a  right  angle,  the  terminal  phalanx  being  flexed,  and 
the  head  of  the  metacarpal  bone  forming  a  prominence  anteriorly 
(Fig.  237).  The  anterior  hgament  is  lacerated,  and  with  the  sesa- 
moid bone  is  pulled  up  on  the  posterior  surface  of  the  head  of  the 
metacarpal  bone,  the  long  flexor  tendon  slipping  to  the  inner  or  the 
outer  side.     The  complex  form  may  be  caused  by  flexion  of  the  thumb 


Fig.  238. 


Fig.  239. 
Pigs.  238  and  239. — Levis  apparatus  for  dislocations  of  the  phalanges. 

in  attempts  to  reduce  the  complete  form.  The  thumb  is  parallel 
with,    but    posterior    to,    the    metacarpal    bone. 

Reduction  consists  in  increasing  the  extension,  making  strong 
traction,  pushing  the  base  of  the  thumb  downwards,  then  pressing 
on  the  head  of  the  metacarpal  bone  and  flexing  the  thumb.  If  this  is 
unsuccessful,  as  it  often  is,  a  palmar  incision  should  be  made  over  the 
head  of  the  metacarpal  bone  and  the  ligament  nicked  between  the 
sesamoid  bones,  when  replacement  will  be  easy.  A  splint  should  be 
used  for  at  least  three^^ weeks. 

Dislocation  of  the  phalanges  may  be  backwards,  forwards  or 
lateral.  Deformity  is  obvious  and  reduction  usually  easy.  In 
difhcult  cases  a  firmer  grasp  on  the  finger  can  be  secured  by  the  Levis 
apparatus  (Figs.  238,  239).  The  fingers  should  be  sphnted  for  one 
week. 

Dislocations  of  the  ribs,  costal  cartilages,  sternum  and  pelvis  are 

30 


466  MANUAL    OF    SURGERY 

very  rare,  and  give  the  same  signs  and  require  the  same  treatment  as 
fractures. 

Dislocations  of  the  hip  are  comparatively  infrequent  owing  to  the 
great  strength  of  the  joint.  The  cause  is  never  direct  violence 
but  always  force  transmitted  from  the  feet  or  knees,  or  from 
the  back  when  the  hips  are  flexed.  After  the  fortieth  or  fiftieth 
year  dislocation  is  very  rare  owing  to  the  fragility  of  the  neck  of  the 
femur,  which  predisposes  to  fracture.  The  upper  portion  of  the  hip 
joint  is  formed  by  the  rim  of  the  acetabulum;  the  capsule  is  markedly 
strengthened  in  front  by  the  iliofemoral  or  Y-ligament  and  to  a  lesser 
degree  by  the  pubofemoral  ligament,  while  posteriorly  it  is  reinforced 
by  the  ischiofemoral  hgament;  hence  the  weakest  portion  of  the 
joint  is  below,  and  it  is  through  this  part  of  the  capsule  that  the  head 
of  the  bone  usually  passes  when  dislocated,  thence  passing  forwards 
or  backwards^according  to  the  presence  of  abduction  at  the  time  of 
the  accident.  The  innominate  bone  is  made  of  two  planes,  the  ilio- 
ischiatic  and  the  pubo-ischiatic,  which  meet  and  form  a  right  angle 
at  a  line  drawn  from  the  anterior  superior  spine  of  the  ilium,  through 
the  acetabulum,  to  the  tuberosity  of  the  ischium.  When  the  head  of 
the  femur  escapes  through  the  lower  portion  of  the  capsule,  it  slides 
off  this  angle  upon  one  or  the  other  of  these  planes,  according  to  the 
direction  of  the  force;  hence  all  dislocations  of  the  hip  are  either  in- 
ward (forward)  upon  the  pubo-ischiatic  plane  or  outward  {backward 
or  dorsal)  upon  the  ilio-ischiatic  plane.  The  head  may  lie  upon  any 
portion  of  either  of  these  planes  within  a  circle  whose  radius  is  the 
untorn  portion  of  the  capsule;  consequently  AUis,  to  whom  belongs 
the  credit  for  working  out  this  problem,  subdivides  the  inward  dis- 
locations into  the  (a)  high  (pubUc  and  subspinous  of  other  writers)  (b) 
middle  (thyroid  of  others),  (c)  low  (perineal  of  others),  and  (d) 
reversed;  and  he  divides  the  outward  or  dorsal  into  the  (a)  high  (on 
dorsum  of  ihum),  (b)  low  (sciatic,  or  dorsal  the  tendon  of  others) 
and  (c)  reversed  (everted  dorsal,  anterior  obHque,  and  supraspinous 
of  Bigelow).  In  three-fourths  of  the  cases  the  dislocation  is  out- 
wards, and  in  two-thirds  of  these  it  is  high,  i.e.,  upon  the  dorsum  of 
the  ilium;  of  the  inward  dislocations  the  middle  (into  the  thyroid 
foramen)  is  the  most  frequent.  Some  writers  state  that  the  head  of 
the  bone  may  be  pushed  through  the  capsule,  e.g.,  by  force  applied 
to  the  knee  when  the  thigh  is  flexed  and  adducted,  directly  onto  the 
dorsum  of  the  ilium,  but  Allis  explains  all  cases  by  leverage;  thus 
outward  dislocations  are  caused  by  flexion,  adduction,  and  inward 
rotation  of  the  thigh,  which  pry  the  head  out  of  the  place  by  the  ful- 
crum action  of  the  iliofemoral  ligament,  which  passes  across  the  front 


JOINTS 


467 


of  the  neck  oi  the  hone;  uuvard  dislocations  are  caused  hy  ahduction, 
the  head  of  the  hone  heing  forced  out  of  the  socket  hy  the  great 
trochanter  impinging  against  the  rim  of  the  acetabulum,  which  acts 
as  the  fulcrum.  The  ligamentum  teres  is  of  course  ruptured.  If 
the  tear  in  the  capsule  is  close  to  the  femur,  its  infolding  may  offer 
an  obstacle  to  reduction.  The  Y-ligament  is  rarely  ruptured;  tear- 
ing of  its  outer  branch  permits  the  femur  to  rotate  externally  and 
results  in  reversed  (everted  dorsal)  dislocations.  If  the  entire  liga- 
ment is  ruptured,  the  head  of  the  bone  will  be 
freely  movable  instead  of  lixed.  The  muscles 
about  the  joint  are  contused  or  lacerated  to 
a  greater  or  lesser  degree.  Rupture  of  the 
obturator  internus  allows  the  head  of  the  bone 
to  ascend  and  become  high  dorsal  if  the  muscle 
remains  intact,  the  low  dorsal  (dorsal  below 
the  tendon)  will  likely  ensue.  It  is  possible, 
however,  for  the  head  to  leave  the  joint  above 
the  tendon  of  this  muscle,  or  leaving  it  lower 
down  to  ascend  in  front  of  the  tendon.  The 
sciatic  nerve  may  be  contused,  compressed 
or  lacerated,  but  the  femoral  vessels  are  very 
rarely  injured. 

In  dorsal  or  outward  dislocation  the  thigh 
is  flexed,  adducted,  rotated  internally,  and 
shortened,  while  the  trochanter  is  above 
Nelaton's  line  and  -farther  away  from  the 
median  line  of  the  body,  so  that  the  hip  ap- 
pears broadened.  A  depression  exists  over  the 
front  of  the  joint  and  the  head  of  the  bone 
can  be  felt  posteriorly.  The  knee  is  flexed 
and   the  heel  raised.     Passive  movement  is       Fig.  240.— High  dorsal 

.,  ,  1       •       ji  T        ,•  c     1    f  •.         dislocation     of     the     hip. 

possible  only  in  the  direction  01  deformity,   (Tiiimanns.) 
and  indeed  the  affected  limb  can  be  flexed  to 

a  right  angle  with  the  body  without  bending  the  knee.  If  both 
knees  are  flexed  while  the  thighs  are  vertical,  the  patient  lying  down, 
the  foot  on  the  affected  side  touches  the  bed.  In  the  high  dorsal 
(Fig.  240)  these  signs  are  all  marked,  in  the  low  dorsal  they  are 
less  in  evidence;  e.g.,  in  the  former  there  is  two  or  three  inches 
shortening,  the  axis  of  the  affected  thigh  passes  through  the  lower 
third  of  the  sound  thigh,  the  foot  passes  over  the  sound  ankle; 
in  the  latter  the  shortening  is  an  inch  or  less,  the  axis  of  the  femur 
passes  through  the  sound  knee,  the  foot  crosses  the  great  toe  of  the 


468 


MANUAL   OF    SURGERY 


sound  side.  In  the  reversed  dorsal  the  lower  limb  is  rotated  exter- 
nally, instead  of  internally  owing  to  tearing  of  the  outer  branch  of 
the  Y-ligament.     For  diagnosis  from  fractures  see  p.  416. 

Reduction  should  be  performed  under  ether  with  the  patient 
lying  on  the  back.  Bigelow's  method  consists  in  flexion  of  the  leg  on 
the  thigh  and  the  thigh  on  the  abdomen,  abduction,  inversion,  strong 
traction  upwards,  and  external  circumduction,  i.e.,  the  knee  is  swept 
upwards  towards  the  opposite  shoulder,  then  towards  the  shoulder 
of  the  same  side,  and  finally  downwards  with  the  limb  in  extension 
(Fig.  241).  As  there  is  some  danger  of  hooking  up  the  sciatic  nerve 
by  the  head  of  femur  in  this  method,  Allis  flexes  the  thigh,  performs 
internal  rotation  by  carrying  the  foot  outwards,  draws  the  thigh  up- 
wards to  lift  the  head  to  the  level  of  the  acetabulum,  and  has  an 

assistant  push  inwards  on  the  head  as  the 
thigh  is  rotated  externally  and  extended. 
In  this  method  it  is  necessary  to  fix  the 
pelvis  firmly  to  the  floor  by  straps  or  by  the 
hands  of  an  assistant.  Rediiction  by  exten- 
sion is  made  by  traction  in  the  axis  of  the 
displaced  thigh  while  pressure  is  made  over 
the  great  trochanter.  Extension  by  pulleys 
destined  to  rupture  the  Y-ligament  is  danger- 
ous and  should  not  be  employed.  After  re- 
duction the  patient  is  confined  to  bed  for 
two  or  three  weeks  with  the  legs  tied 
together. 

Inward  or  forward  dislocations  are 
characterized  by  flexion,  abduction,  and  ex- 
ternal rotation  of  the  thigh.  The  hip  is  flattened,  the  trochanter 
being  nearer  the  median  line;  the  acetabular  cavity  is  empty;  and 
the  head  of  the  bone  may  be  detected  in  its  new  position.  The 
adductor  muscles  are  prominent  and  the  knees  cannot  be  approx- 
imated. In  the  high  thyroid  dislocation,  i.e.,  upon  the  pubes  (Fig. 
242),  flexion  is  less  marked,  but  eversion  is  greater  and  the  limb  is 
shortened  about  one  inch;  in  the  low  thyroid  (Fig.  243)  flexion  is 
greater  and  the  Hmb  is  lengthened  one  or  more  inches.  In  the  re- 
versed thyroid  external  rotation  may  be  so  great  that  the  toes  point 
directly  backwards. 

In  the  reduction  of  inward  dislocations  Bigelow  advised  flexion  of 
the  leg  and  thigh  as  in  the  treatment  of  dorsal  dislocation,  then 
abduction,  eversion,  strong  traction  upwards,  and  internal  circum- 
duction, i.e.,  the  knee  is  swept  upwards  towards  the  shoulder  of  the 


Fig.  241.  —  Bigelow's 
method  of  redtxcing  backward 
dislocation  ot  hip. 


JOINTS 


469 


same  side,  then  towards  the  opposite  shoulder,  and  finally  down- 
wards with  the  limb  in  extension  (Fig.  244).  Allis,  in  order  to  avoid 
injury  lo  the  sciatic  nerve,  flexes  and  abducts  the  thigh,  makes  strong 


Fig.  242. — High  thyroid  (pubic 
dislocation.)      (Tillmanns.) 


Low  thyroid  dis- 
(Tillmanns.) 


traction  upwards,  and  abducts  while  an  assistant  pushes  on  the  head 
of  the  femur.  Reduction  by  extension  alone  is  made  by  traction  in  the 
axis  of  the  displaced  thigh,  the  unshoed  foot 
being  placed  in  the  groin  for  counterexten- 
sion.  After  reduction  the  subsequent  treat- 
ment is  the  same  as  in  the  dorsal  variety. 

The  knee  may  be  dislocated  forward, 
backward,  inward,  or  outward,  and  these 
may  be  complete  or  incomplete,  the  symp- 
toms consequently  varying  in  degree.  The 
cause  is  violent  force,  either  direct  or  indirect. 

In  forward  dislocation  the  lower  end  of 
the  femur  passes  backwards  and  compresses 
the  popliteal  vessels,  and  the  tibia  is  displaced 
forward.     The  leg  is  shortened  and  extended, 

although  it  may  be  flexed;  in  the  former  case  the  patella  is  loose. 
Backward  dislocationfis  more  frequently  due  to  disease  of  the  knee 


Pig.  244. —  Bigelow's 
method  of  reducing  forward 
dislocation  of  hip. 


470  MANUAL    OF    SURGERY 

joint  than  to  injury.  The  leg  is  shortened  and  usually  somewhat 
flexed,  and  compression  of  the  popliteal  vessels  or  nerves  is  generally 
absent.  Inward  and  outward  dislocations  are  usually  incomplete. 
The  leg  is  partly  flexed  and  often  rotated,  but  not  shortened. 

Reduction  is  accomplished  by  traction  and  direct  pressure  while 
the  leg  is  extended  and  the  thigh  flexed.  The  knee  should  be  im- 
mobilized on  a  splint  for  three  weeks,  and  a  support  worn  for  some 
some    time    longer. 

Dislocations  of  the  patella  are  due  to  muscular  action  or  direct 
violence.  An  insidious  outward  dislocation  may  be  caused  by  knock- 
knees  or  hydrarthrosis.  The  patella  may  be  dislocated  upwards, 
downwards,  outwards,  or  inwards,  or  it  may  be  rotated  on  its  per- 
pendicular or  horizontal  axis,  or  there  may  be  a  combination  of  any 
of  these  varieties. 

Dislocation  upwards  or  downwards  is  due  to  rupture  of  the  liga- 
mentum  patellae  or  the  quadriceps  tendon,  and  is  to  be  treated  as  a 
rupture  of  a  tendon. 

Outward  dislocation  is  the  most  frequent  variety;  it  usually 
occurs  when  the  limb  is  extended,  as  in  flexion  the  patella  is  firmly 
held  between  the  condyles  of  the  femur.  The  patella  lies  upon  the 
anterior  or  outer  surface  of  the  external  condyle,  according  to  whether 
the  dislocation  is  incomplete  or  complete;  in  the  former  the  outer 
edge  projects  forward,  in  the  latter  the  inner  border  presents  in  front. 
The  leg  is  extended,  the  knee  broadened,  and  the  intercondyloid  notch 
perceptible.  Reduction  is  made  by  pressure  inwards  on  the  outer 
margin  of  the  patella  while  the  thigh  is  flexed  and  the  leg  extended  to 
relax  the  quadriceps.  Incision  is  needed  in  some  cases.  The  knee 
should  be  immobilized  for  several  weeks. 

Inward  dislocation  is  rare;  the  signs  and  the  treatment  are  the 
reverse  of  those  of  outward  dislocation. 

In  rotation  on  the  perpendicular  axis  (verticle  or  edgewise 
dislocation)  either  the  outer  or  the  inner  border  of  the  patella,  usually 
the  latter,  lies  between  the  condyles  while  the  opposite  border  pro- 
jects forward.  In  two  cases  the  bone  has  been  turned  over,  the 
articular  surface  looking  forwards.  Reduction  may  be  efi'ected  by 
pressure  while  the  knee  is  extended,  but  is  often  more  difl&cult 
than  at  first  sight  appears,  and  incision  may  be  necessary. 

Rotation  on  the  horizontal  axis  has  been  recorded  in  six  instances, 
and  the  author  has  seen  one  case  which  has  not  been  reported.  In 
five  of  these  the  tendon  of  the  quadriceps  was  torn  and  the  upper 
border  of  the  patella  wedged  between  the  femur  and  the  tibia,  in  two 
the  lower  edge  was  torced  into  the  joint,  the  articulating  surface  of  the 


JOINTS  471 

patella  looking  upwards.  In  live  cases  incision  was  necessary  to 
free  the  patella. 

Dislocation  of  the  semilunar  cartilages  of  the  knee  joint  (subluxa- 
tion, internal  dcrangcmoil  of  the  knee  )  follows  a  twist  of  the  partly 
flexed  knee.  The  condyles  fix  the  cartilages,  which  are  torn  from  the 
tibia  by  rotation  of  the  leg,  the  attachments  ol  the  cartilages  to  the 
tibia  being  relaxed  when  the  knee  is  bent.  The  internal  cartilage 
is  the  one  usually  affected.  Any  of  its  attachments  or  even  the 
cartilage  itself  may  be  ruptured. 

The  sjonptoms  are  severe  pain  in  the  knee  and  effusion  into  the 
joint,  which  is  locked  in  flexion,  i.e.,  flexion  may  be  increased  but 
extension  is  impossible.  Sometimes  there  is  no  locking,  and  these 
cases  are  diagnosticated  sprains.  In  the  latter  tenderness  is  more 
generalized,  and  extension  may  relieve  rather  than  increase  the  pain. 
This  displaced  cartilage  is  occasionally  felt,  but  more  often  palpation 
will  reveal  nothing  but  marked  tenderness  along  the  front  of  the 
upper  surface  of  the  tibia.     Recurrences  are  frequent. 

The  treatment  is  reduction  by  increasing  the  flexion,  rotating  the 
leg,  making  firm  pressure  over  the  situation  of  the  displaced  cartilage, 
and  extending  the  leg.  Often  spontaneous  reduction  occurs  before 
the  surgeon  is  called.  The  synovitis  should  be  treated  and  the  knee 
immobihzed  for  five  or  six  weeks.  In  order  to  prevent  recurrence  an 
elastic  knee  cap  should  be  worn  for  several  months.  If  relapses  are 
frequent,  a  brace  may  be  appHed  which,  while  allowing  flexion  and 
extension,  prevents  rotation;  or  the  joint  may  be  opened  by  a 
curved  incision  along  the  upper  edge  of  the  tibia,  and  the  cartilages 
stitched  to  the  periosteum  with  catgut,  or  excised  if  they  are  ruptured 
or  deformed. 

The  fibula  may  be  dislocated  at  either  end,  either  backwards  or 
forwards.  The  injury  is  very  rare.  The  leg  is  flattened  from  side  to 
side  and  a  depression  is  found  over  the  end  of  the  bone,  which  is  felt 
in  its  displaced  position.  Reduction  is  effected  by  flexion  of  the 
knee  and  direct  pressure,  the  leg  being  put  up  in  plaster  of  Paris  for 
several  weeks.  At  the. upper  end  displacement  is  Hkely  to  recur 
owing  to  the  contraction  of  the  biceps. 

Dislocations  of  the  ankle  joint  are  often  compUcated  by  fracture. 
In  the  order  of  their  frequency  the  displacements  are  outwards, 
inwards,  backwards,  forwards,  and  upwards. 

Lateral  dislocation  is  caused  by  a  twisting  or  turning  of  the  foot, 
and  the  resulting  injury  is  a  fracture  dislocation,  known  as  Pott's 
fracture  or  Dupuytren's  fracture,  (q.v.) . 

Dislocation  backwards  is  caused  by  stumbling  when  jumping  or 


472  MANUAL    OF    SURGERY 

running,  or  by  direct  violence;  both  malleoli  are  commonly  broken. 
The  heel  is  prominent,  the  dorsum  of  the  foot  shortened,  and  the 
relations  between  the  malleoli  and  the  tarsus  altered.  Forward 
dislocation  rray  occur  without  fracture.  The  dorsum  of  the  foot 
is  lengthened,  the  heel  inconspicuous,  and  the  normal  hollow  in  front 
of  the  tendo  Achilhs  bulged  by  the  tibia  and  fibula.  Both  these 
dislocations  are  reduced  by  strong  traction,  direct  pressure,  and 
rotation,  while  the  knee  is  bent  to  relax  the  tendo  Achillis,  which  in 
some  instances  it  may  be  necessary  to  sever.  The  after  treatment 
is  that  of  fractures  about  the  ankle. 

Upward  dilsocation  of  the  ankle  is  a  rare  injury  in  which  the 
astragalus  is  thrust  upward  between  the  tibia  and  fibula  as  the  result 
of  a  fall  upon  the  feet.  The  ankle  is  widened  and  the  foot  flattened, 
the  malleoh  having  descended  towards  the  sole  of  the  foot.  Reduc- 
tion is  made  by  powerful  traction  and  countertraction,  the  after 
treatment  being  that  of  fracture. 

In  dislocation  of  the  astragalus  the  bone,  as  the  result  of  falls  or 
twists,  is  detached  from  the  remaining  tarsal  bones  as  well  as  separ- 
ated from  the  bones  of  the  leg.  The  displacement  may  be  complete 
or  incomplete,  the  bone  passing  forwards  or  backwards  or  rotating 
upon  its  perpendicular  or  horizontal  axis;  or  these  lesions  may  be 
combined. 

In  forward  dislocation  the  astragalus  forms  a  prominence  in 
front  of  the  ankle,  the  dorsum  of  the  foot  and  the  leg  are  shortened, 
and  the  malleoh  are  nearer  the  sole  of  the  foot,  which  is  either  turned 
inwards  or  outwards.  In  backward  dislocation  the  astragalus  lies 
between  the  malleoh  and  the  tendo  AchilHs.  If  either  horizontal  or 
vertical  rotary  dislocation  alone  occurs,  the  astragalus  simply 
rotates  mthout  being  displaced  from  between  the  bones  of  the  leg 
and  the  bones  of  the  foot,  a  positive  diagnosis  can  seldom  be  made 
without  the  X  ray. 

Reduction  if  the  bone  is  not  completely  displaced,  is  effected  by 
traction  on  the  foot  and  direct  pressure  on  the  astragalus  while  the 
knee  is  flexed  to  relax  the  calf  muscles.  If  the  dislocation  is  complete, 
reduction  is  rarely  possible,  and  excision  will  be  required. 

Subastragaloid  dislocation  is  a  disrupture  of  the  joints  between 
the  astragalus,  and  the  os  calcis  and  scaphoid,  as  the  result  of  twist- 
ing. It  is  possible  for  the  foot  to  pass  forward,  backward,  inward,  or 
outward,  but  in  most  instances  the  displacement  is  backwards,  or 
inwards,  or  backwards  and  outwards.  If  the  displacement  is 
backuards  and  inwards,  the  external  malleolus  is  prominent,  while  the 
situation  of  the  internal  is  occupied  by  a  hollow.     The  foot  is  inverted 


JOINTS  473 

and  the  astragalus  conspicuous,  thus  resembling  talipes  equino 
varus.  If  the  dislocation  is  hackivards  and  outwards,  the  deformity 
is  the  reverse  of  the  preceding  form  and  resembles  talipes  equino 
valgus.  In  either  of  these  varieties  the  foot  is  shortened  on  the  dorsum 
and  the  heel  elongated,  while  the  tendo  Achillis  forms  a  curve 
which  is  concave  in  the  direction  of  the  displacement. 

Reduction  is  accomplished  by  traction  in  an  opposite  direction 
to  that  of  the  deformity,  the  leg  being  flexed  or  the  tendo  Achillis 
cut  to  secure  muscular  relaxation.  The  foot  and  ankle  are  put  in 
plaster  for  several  weeks. 

Dislocations  of  the  remaining  tarsal  bones  are  quite  rare,  and  are 
treated  by  extension  and  direct  pressure  upon  the  displaced  bone  or 
bones. 

Dislocations  of  the  metatarsal  bones  are  uncommon,  and  cause  a 
backward  or  forward  projection  with  shortening  of  one  toe,  if  one 
bone  is  dislocated,  or  shortening  of  the  entire  foot,  if  all  the  bones  are 
dislocated.  Reduction  is  made  by  extension  and  pressure,  a  -splint 
or  a  cast  being  worn  for  two  or  three  weeks. 

Dislocations  of  the  toes  are  v-ery  rare,  the  metatarso  phalangeal 
joint  of  the  great  toe  being  affected  most  frequently.  The  symptoms 
and  treatment  are  similar  to  those  of    like  injuries  of  the  hand. 

DISEASES  OF  JOINTS 

Examination  of  a  diseased  joint  should  be  preceded  by  obtaining 
the  history  of  the  patient  and  of  the  disease. 

The  cause  of  most  joint  affections  is  injury,  infection,  or  nervous 
disturbances. 

If  the  cause  is  a  severe  injury  and  the  onset  immediate  the  condi- 
tion is  probably  a  sprain,  ruptured  ligament,  intraarticular  fracture 
or  a  dislocation.  A  trivial  injury  followed  by  immediate  distention  of 
a  joint  strongly  suggests  hemarthrosis  due  to  hemophilia.  A  trivial 
injury  followed,  after  an  interval,  by  an  insidious  joint  disease  points 
to  tuberculosis. 

Infection  gains  entrance  through  a  wound,  extends  from  neigh- 
boring structures  (most  often  bone) ,  or  comes  by  way  of  the  blood, 
e.g.,  in  pyemia,  syphiHs,  gonorrhea,  tuberculosis  and  acute  fevers 
(variola,  scarlet  fever,  enteric  fever,  measles,  erysipelas,  pneumonia, 
etc.).  Gout  and  rheumatism  may,  at  least  for  convenience,  be 
placed  under  this  heading,  although  some  might  consider  "faulty 
metabolism"  a  more  appropriate  legend.  "Rheumatism"  is  a  com- 
mon designation  for  many  cases  of  infective  arthritis,  the  source  of 
infection  being  the  tonsil,  prostate,  etc.   (see  diagnosis  of  sepsis) . 


474  MANUAL    OF   SURGERY 

The  nervous  disorders  which  may  be  responsible  for  joint  disease 
are  central  (e.g.,  locomotor  ataxia,  syringomyeHa) ,  peripheral 
(e.g.,  neuritis,  section  of  nerves),  or  emotional  (e.g.,  hysteria). 

As  the  nature  of  hemophilia  is  not  known,  it  will  not  fit  into  any  of 
these  classes. 

The  symptoms  of  a  general  nature,  when  present,  are  those  of 
sepsis  or  of  the  general  diseases  just  mentioned. 

The  local  symptoms  that  annoy  the  patient  are  pain  and  inter- 
ference with  the  Junction  of  the  joint.  If  these  are  intermittent  the 
trouble  may  be  due  to  a  dislocated  cartilage  or  a  loose  body;  if 
remittent  and  chronic  to  osteorathritis.  Chronicity  with  slow 
steady  progress  indicates  tuberculosis.  It  should  be  recalled  that 
pain  may  be  referred  to  distant  parts;  thus  hip  joint  disease  may 
cause  pain  in  the  knee,  disease  of  the  vertebral  joints  in  the  areas 
supplied  by  the  spinal  nervies.  A  number  of  joints  may  be  involved 
in  general  infections,  e.g.,  in  pyemia,  rheumatism,  gonorrhea,  osteoar- 
thritis, and  in  the  acute  infectious  fevers. 

In  the  local  examination  one  should  always  compare  the  joint 
with  that  of  the  opposite  side. 

The  position  of  the  joint  is  generally  one  of  flexion;  in  hysteria  it 
may  be  rigidly  extended. 

The  skin  may  be  white  in  tuberculosis,  ecchymotic  after  injuries, 
hyperemic  in  acute  inflammation.  Numbness  immediately  after 
trauma  may  be  due  to  local  shock;  persistent  anesthesia,  to  nerve 
injury  or  hysteria. 

The  amount  of  swelling  may  be  accurately  determined  with  a 
tape-measure,  being  careful  to  measure  the  corresponding  joints  on 
each  side  of  the  body  at  the  same  place  and  to  have  the  joints  in 
the  same  position.  The  situation,  shape,  and  consistency  of  the 
swelling  should  be  noted.  It  may  involve  the  joint  cavity  alone 
(synovitis),  or  also  the  ends  of  the  bones  (arthritis),  or  it  may  be 
extraarticular,  e.g.,  in  bursitis,  tenosynovitis,  celluHtis. 

Heat,  redness,  and  edema  are  characteristic  of  acute  inflammation, 
some  times  induced,  however,  by  irritating  applications. 

Atrophy  of  neighboring  muscles  may  occur  in  any  case  of  long 
duration,  even  in  hysteria,  but  is  most  marked  in  osteoarthritis 
depending  upon  injury  or  inflammation  of  the  nerves  and  in 
tuberculosis. 

Crepitus  on  pressure  or  motion  may  indicate,  by  its  character 
(p.  7),  blood  clot,  rice  bodies,  synovitis,  or  arthritis.  Its  exact 
situation  must  be  ascertained,  as  it  may  originate  in  adjacent 
bursas  or  tension  sheaths,  a  fact  that  can  sometimes  be  elicited  by 


JOINTS  475 

moving   the   bursa,    e.g.,   prepatellar    bursa,    or   the  tendons,  e.g., 
those  of  the  wrist,  without  moving  the  joint. 

Alteration  of  the  relations  of  the  bony  landmarks  about  a  joint 
indicates  fracture  or  dislocation,  either  of  which  may  be  the  result  of 
injury  or  disease. 

Motions,  both  active  and  passive,  are  usually  restricted  or  abolish- 
ed, but  occasionally  the  joint  may  be  abnormally  movable,  e.  g.,  in 
Charcot's  disease.  Caution  must  be  exercised  to  fix  adjacent  parts 
lest  their  movement  be  wrongly  interpreted  as  belonging  to  the  joint 
under  inspection,  thus  the  scapula  must  be  immobilized  in  examining 
the  shoulder  joint,  the  pelvis  in  examining  the  hip  joint. 

The  X-ray  may  show  distension  of  the  joint  cavity,  lesions  of  the 
cartilages  and  bones,  displacements,  movable  bodies  and  similar 
conditions. 

During  the  second  stage  oi- general  anesthesia  rigidity  due  to 
voluntary  muscular  contraction  ceases,  e.g.,  in  hysteria  and  in  ma- 
lingerers, but  deep  anesthesia  is  necessary  to  relax  involuntary 
muscular  spasm.  Limitation  of  movements  after  complete  anesthesia 
indicates  ankylosis. 

Aspiration  is  indicated  when  the  nature  of  an  effusion  is  doubtful. 

Incision,  for  exploration,  should  be  reserved  for  cases  in  which  all 
other  methods  of  diagnosis  fail  and  in  which  the  disabiHty  is  marked. 

Synovitis  is  inflammation  of  the  synovial  membrane  alone,  the 
remaining  structures  of  the  joint  being  unaffected.  It  may  be 
acute  or  chronic,  simple  or  suppurative. 

Acute  simple  synovitis  is  caused  by  a  closed  injury  (contusion, 
sprain),  low  grade  infection,  or  nervous  influences  (p.  474).  The 
synovial  membrane  is  red  and  swollen,  and  the  joint  is  distended 
with  fluid  consisting  of  synovia,  inflammatory  exudate,  and  some- 
times blood,  hence  it  is  coagulable.  Precipitated  lymph  may  be 
absorbed,  or  become  organized  and  result  in  adhesions. 

The  symptoms  are  pain,  tenderness,  increased  heat,  a  fluctuating 
swelling,  and  in  some  cases  hyperemia  of  the  skin.  The  muscles 
fix  the  joint  in  the  most  comfortable  position,  usually  some  degree 
of  flexion,  in  which  position  there  is  more  room  for  the  fluid.  The 
effusion  stretches  the  softer  tissues  entering  into  the  formation 
of  the  joint  and  leaves  it  a  little  weakened  and  relaxed,  at 
least  temporarily.  The  constitutional  symptoms  vary  with  the  cause 
of  the  synovitis  and  the  size  of  the  joint.  Effusion  is  detected  in  the 
various  joints  as  follows:  The  shoulder  is  increased  in  size,  and 
swelling  may  be  noticed  along  the  bicipital  groove  and  in  the  axilla. 
In  subdeltoid  bursitis  axillary  swelHng  is  absent,   and,   although 


476 


MANUAL    OF    SURGERY 


active  motions  are  painful,  gentle  passive  movements  of  the  shoulder 
may  be  painless.  In  the  elbow  the  swelling  is  on  each  side  of  the 
olecranon  and  tendon  of  the  triceps.  In  the  wrist  swelling  is  most 
marked  posteriorly.  In  the  Jiip  effusion  is  usually  not  detected, 
but  reliance  is  placed  upon  the  tenderness,  limitations  of  movements 
and  upon  the  position  of  the  thigh  in  flexion,  abduction,  and  external 
rotation.  In  the  knee  swelling  is  detected  upon  each  side  of  the 
patella  and  its  ligament,  and  beneath  the  quadriceps.  The  patella  is 
floated  away  from  the  condjdes,  and  if  tension  is  not  too  great  it  may 


Fig.  244a. — Lateral  incisions  for  drainage 
of  knee  joint. 


Fig.  2446. — Posterior 
incisions  for  drainage  of 
knee  joint. 


be  pushed  backward  by  the  finger  and  made  to  tap  on  the  femur.  In 
the  ankle  fullness  may  be  seen  in  front,  but  is  most  in  evidence  on 
each  side  of  each  malleolus. 

The  treatment  is  immobihzation  and  elevation  of  the  joint,  and  in 
the  first  stage  cold  in  the  form  of  an  ice  bag  or  evaporating  lotions 
later  absorption  should  be  promoted  by  the  use  of  heat,  compression; 
and  ointments  containing  ichthyol,  belladonna,  mercury,  or  iodin. 
If  the  effusion  is  large  or  unaffected  by  other  forms  of  treatment 
aspiration  may  be  advisable.  The  position  of  the  joint  should  be 
such  as  to  give  a  useful  limb  even  in  the  event  of  ankylosis.     Thus 


JOINTS  477 

the  elbow  is  j)ut  on  an  internal  an,u;ular  splint,  the  hip  and  knee  are 
fixed  in  extension,  the  wrist  midwa}-  between  flexion  and  extension, 
the  ankle  at  a  right  angle,  and  the  shoulder  with  the  arm  to  the  side. 
Traction  by  means  of  adhesive  plaster,  as  for  fracture,  is  of  service 
when  the  hip  or  knee  is  involved.  During  the  convalescing  stage, 
liniments,  massage,  and  elastic  compression  are  useful.  As  soon  as 
the  intlammation  has  subsided  gentle  passive  motions  should  be 
started,  in  order  to  prevent  ankylosis. 

Acute  suppurative  synovitis  {empyema  of  a  joint)  may  be  a  later 
stage  of  simple  synovitis.  More  commonly  it  is  suppurative  from 
the  onset,  the  cause  being  an  open  w^ound,  neighboring  inflammatory 
process,  or  a  hematogenous  infection  (pyemia).  The  symptoms  are 
those  of  simple  synovitis,  but  more  intense,  and  accompanied  by 
marked  general  evidences  of  sepsis.  The  diagnosis  may  be  confirmed 
by  exploratory  puncture.  The  treatment  is  that  of  acute  suppurative 
arthritis,  into  which  untreated  suppurative  synovitis  merges. 

Chronic  simple  synovitis  follows  the  acute  form  or  is  chronic 
from  the  beginning.  The  synovial  membrane  is  thickened  and  the 
joint  contains  an  excess  of  fluid,  which,  when  large  in  quantity,  is  called 
hydrops  articuli.  The  symptoms  are  slight  pain  when  the  joint  is 
moved,  fluctuation  owdng  to  the  presence  of  effusion,  weakness  with 
restriction  of  motion,  atrophy  of  neighboring  muscles,  and  in  some 
cases  cerpitus  on  pressure  or  when  the  thickened  layers  of  synovial 
membrane  are  rubbed  together  by  motions  of  the  joint.  In  some 
situations,  e.g.,  the  knee,  hypertrophied  synovial  fringes  may  be 
palpated. 

The  treatment  is  immobilization,  compression,  and  counterirrita- 
tion  with  blisters,  iodin,  or  occasionally  the  actual  cautery;  stimu- 
lating liniments  and  massage  are  useful,  as  an  ointment  containing 
equal  parts  of  ichthyol,  belladonna,  mercury,  and  lanolin.  Baking 
the  joint  by  means  of  a  hot-air  apparatus  or  radiant  heat,  usually 
gives  at  least  temporary  relief.  Aspiration  is  occasionally  employed. 
Arthrotomy  is  reserved  for  cases  which  resist  all  other  forms  of 
treatment.  In  these  cases  the  joint  is  irrigated  with  salt  solution 
and  hypertrophied  fringes  removed;  other  undiagnosticated  con- 
ditions, such  as  loose  bodies,  ruptured  or  inflamed  semilunar  car- 
tilages, lipoma  arborescens,  tuberculous  disease,  etc.,  may  be  found 
and  will  require  treatment.  Constitutional  treatment,  of  course 
should  be  administered  in  the  presence  of  any  diathesis. 

Chronic  suppurative  synovitis  is  usually  a  legacy  of  the  acute 
form,  or  when  originating  insidiously,  due  to  syphiUs  or  tuberculosis, 
under  which  headings  the  treatment  will  be  considered. 


478  MANUAL   OF    SURGERY 

Arthritis  {panarthritis)  is  inflammation  of  not  only  the  synovial 
membrane,  but  also  the  cartilages,  bones,  and  hgaments  of  an  articu- 
lation, in  a  word  all  the  structures  of  a  joint.  Clinically,  arthritis  is 
distinguished  from  synovitis  by  the  tender,  swollen  articular  ends 
of  the  bones,  by  the  greater  pain  on  active  as  compared  with  passive 
motion,  and  in  the  later  stages,  after  the  cartilages  and  bones  have 
become  eroded,  by  starting  pains  p.  481),  by  cartilaginous  or  bony 
crepitus,  and  by  the  X-ray.  Arthritis  is  classified  like,  and  is  due 
to  the  same  causes  as,  synovitis. 

Acute  and  chronic  simple  arthritis  are  treated  like  acute  and 
chronic  simple  synovitis.  Joint  inflammations  occurring  during  or 
after  acute  infectious  fevers  commonly  terminate  without  suppura- 
tion the  symptoms  being  much  like  those  of  rheumatic  synovitis, 
one  or  several  joints  being  involved.  In  some  cases,  notably  in 
typhoid  arthritis,  there  is  little  pain,  although  dislocation  may  occur. 
In  some  cases  aspiration  of  the  joint,  with,  if  need  be,  microscopic 
examination  of  the  fluid,  will  reveal  the  presence  or  absence  of  pus. 

Acute  suppurative  arthritis  is  always  due  to  micro-organisms 
which  enter  the  joint  through  a  wound,  from  neighboring  tissues 
or  by  way  of  the  blood,  e.g.,  in  pyemia  and  acute  infectious  diseases. 
The  entire  joint  and  the  periarticular  structures  participate  in  the 
inflammation,  which  destroys  the  cartilages,  relaxes  the  ligaments 
(sometimes  permitting  luxation) ,  and  invades  the  neighboring  bone 
and  soft  structures. 

The  symptoms  are  great  pain  and  tenderness,  and  j&xation  of  the 
joint,  which  is  hot,  swollen,  and  fluctuating.  There  are  redness 
and  edema  of  the  skin  and  severe  constitutional  symptoms  (septic 
intoxication  or  septicemia) .  The  ends  of  the  bones  enlarge  (ostitis) , 
and  finally,  in  progressing  cases,  ulcerate  (caries),  at  which  time 
starting  pains  (p.  481)  may  occur  and  osseous  crepitus  be  obtained. 
If  proper  treatment  is  withheld  and  the  patient  sur\'ive,  pus  per- 
forates the  capsule,  infiltrates  the  surrounding  tissues,  and  finally 
breaks  through  the  skin,  the  joint  becoming  abnormally  movable 
and  dislocated  to  a  greater  or  lesser  degree.  The  patient  may  die 
from  toxemia  during  the  acute  stage,  or  succumb  to  chronic  infection 
and  exhaustion  in  the  later  stages.  Should  recovery  ensue  ankylosis 
is  almost  inevitable. 

The  treatment  consists  in  freely  opening  the  joint,  irrigating 
with  salt  or  Dakin's  solution,  establishing  free  drainage,  institut- 
ing chemical  sterilization  p.  149-150-151  and  treating  constitutionally 
as  for  sepsis.  No  drainage  material,  i.e.,  rubber  tubing  or  gauze, 
should  be  introduced  into  the  synovial  sock.     Willems  institutes 


JOINTS  479 

motion  in  the  joint,  passive  and  active,  beginning  immediately  after 
operation.  Excision  or  amputation  will  be  required  if,  after  free 
drainage  septic  symptoms  threaten  life.  Murphy  treats  infective 
athritis  by  aspirating  the  fluid  and  injecting  lo  cc.  of  a  2  per  cent, 
dilution  of  formahn  in  gylcerine.  This  procedure  is  repeated  every 
few  days  if  the  effusion  reappears.  Others  have  great,  and  we  think 
unwarranted,  faith  in  vaccine  therapy. 

Chronic  suppurative  arthritis  follows  the  acute  form,  or  is  due  to 
one  of  the  infective  granulomata,  notably  syphilis  or  tuberculosis 
(vide  infraV 

Pneumococcal  arthritis  is  due  to  pneumococcemia,  although  the 
organism  is  not  always  recoverable  from  the  blood.  The  original 
infection  is  usually  a  lobar  pneumonia,  sometimes,  however,  a 
pneumococcal  meningitis  or  peritonitis ;  rarely  a  primary  focus  cannot 
be  found.  In  about  two-thirds  of  the  cases  only  one  joint,  usually 
the  knee,  is  affected.  The  effusion  may  be  serous,  but  is  generally 
purulent.  The  diagnosis  is  made  by  bacteriologic  examination  of 
the  aspirated  joint  fluid.  The  treatment  is  that  of  simple  or  sup- 
purative arthritis,  according  to  whether  the  fluid  is  serous  or  purulent. 

Gonorrheal  arthritis  {gonorrheal  rheumatism)  is  due  to  the  gonoco- 
ccus,  which  is  carried  by  way  of  the  blood  from  the  urethra,  or 
rarely  from  the  conjunctiva  in  gonorrheal  ophthalmia.  As  a  rule  it 
appears  during  the  subsiding  stages  of  an  acute  gonorrhea  or  in 
chronic  cases.  Men  are  said  to  be  more  frequently  affected  than 
women,  but  this  is  probably  owing  to  the  fact  that  the  diagnosis  is 
seldom  made  in  the  latter.  One  or  several  joints  may  be  involved, 
generally  the  former,  the  knee,  ankle,  and  wrist  being  most  fre- 
quently affected.  The  inflammation  may  be  acute  or  chronic,  and 
varies  in  extent  as  well  as  in  degree.  Although  the  s^movial  mem- 
brane alone  may  be  involved,  the  Hgaments  and  periarticular  struc- 
tures are  very  apt  to  be  thickened  and  infiltrated.  Except  in  the 
mildest  cases,  the  pain  is  severe  and  there  is  fever.  Suppuration 
may  occur,  and  ankylosis  is  xery  prone  to  follow  even  the  milder 
cases.  Endocarditis  and  like  compKcations  of  general  infection 
occasionally  occur.  In  doubtful  cases  some  of  the  fluid  from  the 
joint  may  be  secured  by  aspiration  for  bacteriological  examination. 
The  complement-fixation  test  for  gonorrhea,  if  positive  is  of  the 
greatest  value  in  many  obscure  articular  inflammations,  but  of  no 
significance  when  negative. 

The  treatment  is  unsatisfactory  the  disease  being  apt  to  persist 
or  recur.  The  urethritis  should  be  combated,  the  seminial  vesicles 
carefully  examined  and  drained  or  excised  if   necessary,  and  the 


480  MANUAL    OF    SURGERY 

joints  immobilized  and  treated  locally  as  in  other  forms  of  arthritis. 
As  soon  as  the  pain  subsides,  passive  motions  should  be  employed 
to  prevent  ankylosis.  Among  the  internal  remedies  which  have 
been  used  are  the  salicylates,  iron,  quinin,  strychnin,  and  the  iodids. 
If  suppuration  occurs,  the  joint  should  be  opened,  irrigated,  and 
drained.  Rogers  and  Torrey  claim  good  results  from  the  hypoder- 
mic injection  of  an  antigonococcus  serum,  prepared  by  injecting 
cultures  of  the  gonococcus  into  rabbits.  From  twenty  to  sixty 
minims  are  administered  every  day  or  every  other  day  until  the 
pain  and  disability  subside.  Vaccines  made  from  the  gonococcus 
also  have  been  employed. 

S3rphilitic  gummatous  arthritis  occurs  in  the  tertiary  period. 
The  onset  is  insidious;  the  disease  begins  in  one  portion  of  the  joint, 
and  is  associated  with  but  little  pain.  If  unchecked  it  finally 
reaches  the  surface,  when  the  characteristic  gummatous  material  will 
be  exposed.  The  symmetrical  form  of  synovitis  occurring  in  the 
secondary  period  has  already  been  mentioned.  There  is  also  a  form 
of  gummatous  synovitis  resembling  tuberculosis,  and  a  form  of 
chondroarthritis  analogous  to  osteoarthritis.  The  history,  the 
evidences  of  syphilis  elsewhere,  the  Wassermann  reaction,  and  the 
response  to  appropriate  treatment,  are  important  factors  in  making 
the  diagnosis.  The  treatment  is  that  of  syphilis;  excision  or  amputa- 
tion may  sometimes  be  required. 

Tuberculous  arthritis  [-d:liite  swelling,  pulpy  degeneration)  is 
much  more  common  in  children,  the  joint  generally  being  invaded 
from  an  adjacent  epiphysis;  in  adults  the  primary  focus  is  probably 
in  the  synovial  membrane  as  often  as  it  is  in  the  neighboring  bone. 
The  tubercle  bacillus  is  transported  by  the  blood  to  the  joint,  in 
which  an  area  of  lessened  resistance  has  often  been  created  by  some 
slight  injury,  the  patient  possessing  a  hereditary  predisposition  to 
the  disease. 

The  pathological  anatomy  is  as  follows:  When  beginning  in  the 
synovial  membrane,  whitish  or  pinkish  pulpy  granulations  are  formed 
and  eventually  fill  the  joint,  giving  a  characteristic  doughy  feel. 
In  other  cases  the  membrane  is  covered  with  small  tubercles  and  the 
joint  is  filled  with  fluid.  The  tubercles  caseate  and  liquefy,  forming 
tuberculous  pus.  The  ligaments  become  softened  and  finally 
destroyed;  the  cartilages  are  eroded  and  eventually  the  bones;  and 
the  surrounding  soft  tissues  are  edematous.  When  the  disease 
begins  in  the  bone,  the  changes  are  those  of  tuberculous  ostitis,  the 
joint  being  aft'ected  secondarily.  In  any  case  the  tuberculous  pus 
generally  finds  its  way  to  the  exterior  by  one  or  more  sinuses. 


JOINTS  481 

Tlu-  symptoms  are  very  slow  in  onset.  At  first  there  is  slight 
pain,  causing  some  limitation  of  motion  and,  in  the  lower  extremities, 
limping.  Later,  swelling  is  noticed  and  the  muscles  rigidly  hold  the 
joint  in  a  semiflexed  position.  In  a  well  developed  case  the  joint  is 
spindle-shaped,  due  not  only  to  the  swelling,  but  also  to  the  atrophy 
of  the  neighboring  muscles,  and  the  skin  is  white,  owing  to  oblitera- 
tion of  the  subjacent  vessels,  and  is  adherent  to  the  parts  beneath. 
A  peculiar  doughy  or  elastic  sensation  is  imparted  to  the  fingers  on 
palpation,  but  fluctuation  is  detected  only  when  a  cold  abscess 
approaches  the  surface,  or  in  the  rare  cases  in  which  the  effusion 
predominates.  Rice  bodies  are  sometimes  found  in  the  latter  variety. 
Night  cries  {starting  pains)  indicate  erosion  of  cartilage  or  bone; 
when  the  patient  falls  asleep  the  rigid  muscles  relax,  permitting 
some  alteration  in  the  relation  of  the  joint  surfaces,  and  producing 
severe  pain  which  causes  the  patient  to  wake  with  a  start.  Partial 
or  even  complete  luxation  may  be  induced  by  tonic  contractions  of 
the  muscles  upon  the  disorganized  joint.  The  local  temperature  of 
the  joint  is  raised,  and  later,  when  sinuses  form,  hectic  fever  develops 
owing  to  mixed  infection. 

The  diagnosis  may  be  difficult  in  the  early  stages,  in  deep  seated 
joints,  and  in  cases  with  a  large  effusion,  which  resembles  chronic 
synovitis.  The  examination  of  aspirated  fluid  and  the  X-ray  are 
often  of  great  value,  and  some  recommend  the  tuberculin  test. 
Doubtful  cases  should  be  regarded  as  tuberculous. 

With  proper  treatment  the  prognosis  is  good  regarding  life, 
metastases  being  uncommon.  Ankylosis  generally  follows,  and 
indeed  is  nature's  method  of  cure.  In  late  cases,  i.e.,  those  with 
sinuses,  the  patient  may  develop  amyloid  disease  or  die  of  exhaustion. 

The  treatment  is  constitutional  (see  tuberculosis)  and  local.  The 
local  treatment  may  be  conservative  or  radical.  Conservative 
treatment,  which  is  indicated  in  the  early  stages,  includes  immobiliza- 
tion, often  for  months,  by  feplint,  plaster-of-Paris,  or  extension 
apparatus;  baking  with  the  hot-air  machine;  Bier's  passive  hypere- 
mia; aspiration  of  the  joint  fluid  and  injection  of  10  per  cent,  iodo- 
form emulsion  (two  to  five  drams  according  to  the  age  of  the  patient) 
or  other  antiseptic  (see  tuberculosis)  at  intervals  of  a  w-eek  or  longer; 
phototherapy  (Finsen  light) ;  radiotherapy  (radium,  X-rays) ;  and 
heliotherapy  (see  tuberculosis).  Compression,  counterirritation, 
and  external  applications  of  various  lotions  and  ointments  are  useless. 
As  soon  as  detected,  absceses  should  be  tapped  with  a  large  trocar 
and  cannula,  irrigated  with  salt  solution,  and  injected  with  iodoform 
emulsion.     If  sinuses  exist  injections  of  Beck's  bismuth  paste  may 

31 


482  MANUAL    OF    SURGERY 

be  tried  before  proposing  operation  (see  section  on  sinus).  If  the 
disease  continues  to  progress,  or  if  the  general  condition  of  the  patient 
is  such  as  to  forbid  prolonged  treatment,  radical  measures  are  de- 
manded. The  joint  should  be  opened  and  the  tuberculous  tissue 
removed  by  erasion  (arthrectomy)  or  excision,  according  to  its 
extent.  Amputation  is  indicated  in  cases  too  far  advanced  for 
excision,  or  in  cases  in  which  excision  has  failed. 

Tuberculosis  of  Special  joints. — In  the  shoulder  joint  the  disease 
is  more  frequent  in  adults  than  in  children,  but  is  not  common  in 
either.  It  usually  begins  in  the  head  of  the  humerus  and  rarely 
attacks  the  glenoid  cavity.  Abscesses,  which  are  rather  unusual, 
point  on  either  side  of  the  deltoid  or  in  the  axilla.  In  caries  sicca, 
which  occurs  more  often  here  than  in  any  other  joint,  instead  of 
doughy  swelhng,  there  is  shrinkage  due  to  muscular  atrophy  and 
destruction  of  the  head  of  the  humerus.  Immobilization  should  be 
persisted  in  for  a  number  of  months.  If  sinuses  form,  however, 
excision  of  the  head  of  the  humerus  will  usually  be  required. 

The  elbow  is  affected  more  often  than  either  the  shoulder  or  the 
wrist,  because  the  nutrient  arteries  of  the  humerus,  radius,  and  ulna 
run  towards  the  elbow,  thus  favoring  the  deposition  of  bacterial 
emboli  in  this  region.  The  disease  is  most  frequent  during  adoles- 
cence, beginning,  in  the  order  of  their  frequency,  in  the  synovial 
membrane,  or  in  the  epiphysis  of  the  humerus,  ulna,  or  radius.  The 
characteristic  spindle-shaped  swelling  is  well  marked.  Abscesses 
point  on  either  side  of  the  olecranon,  or  occasionally  follow  the  ulnar 
nerve  and  present  on  the  inner  side  of  the  arm.  Immobilization  at  a 
right  angle,  with  the  forearm  midway  between  pronation  and  supina- 
tion, is  the  correct  treatment  in  the  early  stages,  but  if  the  bones  are 
much  involved,  either  erasion,  or  in  adults  excision,  is  the  quickest 
and  best  treatment. 

Tuberculosis  of  the  wrist  is  comparatively  infrequent,  but  may 
be  met  with  at  all  ages.  It  may  begin  in  the  synovial  membrane, 
or  be  secondary  to  disekse  in  the  carpal  bones,  lower  end  of  the  radius, 
or  neighboring  tendon  sheaths.  If,  after  several  months  of  conserva- 
tive treatment,  the  disease  is  not  checked,  erasion  or  excision  is 
usually  advisable,  and  if  the  disease  is  very  extensive,  amputation 
will  offer  the  only  hope  or  relief. 

Tuberculosis  of  the  sacroihac  joint  is  of  infrequent  occurrence, 
and  is  most  commonly  seen  in  adults.  It  may  be  synovial  in  origin 
but  more  often  arises  in  adjacent  bones.  There  is  pain  in  the  back, 
in  the  joint,  or  down  the  thigh,  which  is  increased  on  standing,  walk- 
ing, or  rocking  the  pelvis  with  the  hands.     The  patient  limps  and 


JOINTS  483 

puts  most  of  his  weight  011  the  sound  leg,  the  body  being  bent  for- 
ward and  away  from  the  affected  side,  thus  causing  apparent  lengthen- 
ing of  the  limb  corresponding  to  the  diseased  joint.  There  may  be 
swelling  and  tenderness  directly  over  the  articulation,  and  in  the 
later  stages  abscesses  discharge  in  this  situation,  in  the  lumbar  region, 
in  the  iliac  fossa,  in  the  groin,  or  even  alongside  the  rectum. 

The  diagnosis  may  be  difficult  in  the  early  stages.  Lumbago 
follows  exposure  to  cold,  affects  both  sides,  and  is  transient  in  charac- 
ter. Sciatica  causes  a  very  severe  shooting  pain,  tenderness  of  the 
nerve,  no  apparent  lengthening  of  the  limb,  and  no  increase  in  pain 
when  the  iliac  bones  are  pressed  together  or  pulled  apart.  Hip 
disease  causes  rigidity  of  adjacent  muscles  and  hmitation  of  hip 
movements,  which,  if  the  pelvis  is  supported,  are  not  present  in 
sacroiliac  disease.  If  there  is  an  iliac  abscess  in  sacroiliac  disease, 
the  thigh  may  be  flexed,  but  the  hip  can  be  freely  moved.  In  disease 
of  the  spine  there  are  pain,  tenderness,  rigidity,  and  perhaps  deformity 
in  the  affected  segment.    "Theprog-  _,--., 

nosis,  owing  to  the  deep  situation 
of  the  joint,  is  often  unfavorable. 

The  treatment  is  rest  in  bed  with 

a  felt  or  plaster-of-Paris  case  for  Pig.  245. — Lordosis  of  lumbar  spine, 
^1  1    •  Tf     1  r  ^T-        disappearing,  as  indicated  bv  the  dotted 

the  pelvis.     If  abscesses  form,  the    ^^^  ^^en  the  thigh  is  flexed. 
joint  should  be  opened,  and  the  dis- 
eased tissue  removed  as  thoroughly  as  possible,  with  gouge,  chisel,  or 
curette. 

Hip  joint  disease  {morbus  coxce,  coxitis,  coxalgia)  without  qualifi- 
cation means  tuberculosis  of  the  hip,  although  any  other  form  of 
joint  disease  may  occur  in  this  articulation.  The  disease  may  origin- 
ate in  any  of  the  structures  of  the  joint,  but  the  primary  lesion  is 
most  often  in  the  femoral  epiphysis.  It  is  very  much  more  frequent 
in  children  than  in  adults. 

The  symptoms  in  the  beginning  are  shght  lameness  and  stiffness 
of  the  hip.  Pain  is  present  in  the  hip  or  along  the  inner  side  of  the 
knee  (both  joints  being  suppHed  by  the  obturator  nerve),  and  is 
increased  by  movements  of  the  joint.  Very  likely  a  history  of 
tuberculous  disease  in  the  immediate  ancestors,  and  a  history  of  a 
shght  injury,  will  be  obtained.  Examination  reveals  hmitation  of 
the  movements  of  the  hip  and  slight  flexion,  due  to  rigidity  of  the 
muscles  which  guard  the  joint.  With  the  child  in  the  recumbent 
posture  the  lumbar  spine  wiU  curve  forwards  if  the  knee  on  the  affected 
side  is  pressed  down  to  the  table  (Fig.  245) .  Slight  fullness  about  the 
joint  or  muscular  atrophy  may  be  observed  at  this  time.     With  the 


484 


MANUAL    OF    SURGERY 


progress  of  the  disease  flexion  increases  and  is  associated  with  abduc- 
tion and  eversion  of  the  thigh,  a  position  which  relaxes  the  ligaments, 
increases  the  capacity  of  the  joint,  and  thus  secures  the  greatest 
comfort.  If  the  patient  stands  or  walks,  most  of  the  weight  is  borne 
on  the  sound  leg,  causing  lowering  of  the  pelvis  on  the  diseased  side 
with  apparent  lengthening  of  the  limb  (Fig.  246-B),  and  a  compensa- 
tory lateral  curve  of  the  lumbar  spine,  convex  towards  the  affected 
side.  Flexion  may  be  obscured  by  compensatory  lordosis,  abduction 
by  tilting  of  the  pelvis  and  lateral  curving  of  the  lumbar  spine,  but 
eversion  is  never  masked.  At  this  stage  muscular  rigidity  is  well 
marked,  the  pelvis  moving  upon  any  attempt  to  move  the  thigh;  if 
the  lumbar  spine  is  made  to  approach  the  table  by  flexing  the  sound 
thigh  on  the  abdomen,  the  thigh  on  the  diseased  side  wifl  rise  accord- 


FiG.  246. — A.  Abducted  thigh.  B.  Apparent  lengthening  when  limbs  are  parallel. 
C.  Adducted  thigh.  D.  Apparent  shortening  when  limbs  are  parallel.  Note  the  effect 
on  the  pelvis  and  the  lumbar  spine. 

ing  to  the  amount  of  flexion  present.  The  gluteal  crease  is  obliterated 
(due  to  muscular  atrophy  and  flexion)  or,  if  present,  is  on  a  lower 
level  than  its  fellow,  and  some  fullness  may  be  detected  in  the  upper 
part  of  Scarpa's  triangle.  Pain  increases,  is  rendered  more  severe 
by  any  jarring  motion  to  the  knee  or  foot,  and  is  apt  to  wake  the 
patient  suddenly  from  sleep  {night  cries,  starting  pains).  Abscesses 
may  now  form  and  point  in  the  buttock,  above  or  below  Poupart's 
ligament,  on  the  inner  side  of  the  thigh,  or  most  frequently  at  the 
front  of  the  great  trochanter;  hectic  fever  is  thus  established,  and 
anemia  and  emaciation  become  more  marked.  The  ligaments  are 
softened  and  weakened,  the  limb  flexed,  adducted,  and  inverted,  the 
pelvis  elevated  on  .the  diseased  side,  and  the  lumbar  spine  convex 
towards  the  sound  side.     Hence  the  hmb  appears  shortened  (Fig. 


JOINTS  485 

246-D) ;  later,  owing,  to  erosion  of  f)one  or  in  some  cases  to  dislocation 
backwards,  real  shortening  becomes  evident.  Ankylosis  and  re- 
covery are  possible  at  any  period;  death  occurs  from  tuberculosis 
elsewhere,  or  in  the  late  stages  from  septicemia,  exhaustion,  or 
amyloid  disease. 

The  diagnosis  may  be  very  difficult  in  the  early  stages.  The 
patient  should  always  be  stripped  and  both  sides  carefully  examined. 
Pain  in  the  knee,  especially  in  a  child,  always  indicates  a  careful 
examination  of  the  hip.  Spinal  disease,  sacroiliac  disease,  infantile 
paralysis,  and  other  conditions  not  immediately  connected  with 
the  joint  are  not  associated  with  restricted  motions  of  the  hip. 
In  inflammation  of  the  iliopsoas  bursa  there  may  be  pain  on  extend- 
ing the  hip,  but  after  flexion  the  thigh  may  be  rotated  without  dfs- 
comfort.  In  gluteal  bursitis  there  may  be  limp  and  restriction  of 
motion,  but  not  the  characteristic  deformity  of  hip  disease;  in  some 
cases  fluctuation  or  crepitus  may  be  obtained  over  the  bursa.  In 
flexion  of  the  thigh  due  to  intraabdominal  disease,  the  movements 
of  the  hip  are  free.  Any  form  of  joint  disease  may  occur  in  the  hip, 
and  if  the  synovial  cavity  is  distended  there  will  be  flexion,  ab- 
duction, and  eversion.  Chronic  inflammation  of  the  hip  in  child- 
hood should,  however,  always  be  regarded  as  tuberculous  unless 
proved  otherwise.  The  X-ray  is  of  value  in  differentiating  from 
dislocation  and  in  determining  the  presence  and  extent  of  bone 
disease.  The  prognosis  is  favorable  if  the  diagnosis  is  made  early 
and  the  proper  treatment  instituted.  In  the  later  stages  recovery 
will  always  be  associated  with  shortening  and  ankylosis. 

The  treatment  in  the  early  stages  is  rest  in  bed,  and  traction  by 
Buck's  extension  apparatus  to  overcome  muscular  spasm  and 
prevent  deformity.  If  flexion  is  marked,  extension  should  be  at 
first  in  the  axis  of  deformity,  and  as  the  muscular  spasm  diminishes, 
it  may  be  gradually  lowered  to  a  horizontal  position.  Young 
children  who  are  difficult  to  keep  still  should  be  strapped  to  a 
Bradford  frame.  The  proper  weight  for  traction  will  vary  between 
one  and  six  pounds  or  more,  according  to  the  age  and  the  effects  of 
the  extension.  The  constitutional  treatment  is  that  of  tuberculosis 
(q.v.).  When  the  deformity  has  been  corrected  and  pain  has 
subsided,  a  brace  may  be  appHed  and  the  patient  allowed  to  get 
about  on  crutches.  Of  the  many  mechanical  appliances  w^hich 
have  been  used,  the  Thomas  hip  spHnt  (Fig.  247)  or  one  of  its 
modifications  is  the  most  useful.  A  patten  or  thick  soled  shoe  is 
worn  on  the  foot  of  the  sound  side,  and  the  patient  walks  with 
crutches,  the  affected  limb  hanging  some  distance  away  from  the 


486 


MANUAL    OF   SURGERY 


ground,  thus  acting  as  an  extension  weight.  In  the  presence  of 
deformity  the  brace  may  be  bent  to  accomodate  itself  to  the  altered 
position  of  the  limb.  Some  surgeons  apply  plaster-of-Paris  to  the 
limb  and  pelvis.  Traction  splints  are  those  which  may  be  length- 
ened by  a  sliding  rod  or  movable  foot  piece,  counterextension  being 
supplied  by  perineal  bands.  A  brace  should  be  worn  for  six  months 
after  all  symptoms  have  disappeared.  Intraarticular  injections 
of  iodoform  or  other  antiseptics  are  occasionally  used.  Abscesses 
should  be  tapped  with  trocar  and  cannula  and  injected  with  iodo- 
form emulsion.  Sinuses  may  be  injected  with  Beck's  paste,  but 
if  they  persist  or  recur  they  should  be  explored,  and  necrotic  or 
carious  bone  removed  by  erasion.  Formal  resection  of  the  hip 
results  in  immediate  shortening,  and  in  children 
interfere  with  the  growth  of  the  femur,  so  that 
it  should  not  be  performed  unless  the  disease 
progresses  despite  other  means  of  treatment. 
If  excision  fails,  or  if  there  is  an  extensive 
osteomyelitis  of  the  femur,  amputation  will  be 
required. 

The  knee,  with  the  possible  exception  of 
the  hip,  is  more  frequently  attacked  by  tuber- 
culosis than  any  other  joint.  The  term  white 
swelling  when  used  alone  means  tuberculosis  of 
the  knee.  In  children  the  disease  usually 
begins  in  the  lower  end  of  the  femur,  in  adults 
in  the  synovial  membrane.  The  symptoms  are 
those  of  joint  tuberculosis  in  general.  Flexion 
is  present,  and  in  the  later  stages  backward  dis- 
location of  the  tibia  often  occurs.  The  treatment 
is  immobihzation  with  plaster-of-Paris  or  a  traction  knee  splint 
(Fig.  248).  Other  conservative  methods  also  may  be  employed.  If 
the  progress  of  the  disease  is  not  checked  by  these  measures,  or  if 
the  case  is  seen  in  a  late  stage,  erasion  or  excision  will  be  indicated. 
Amputation  should  be  reserved  for  cases  in  which  the  disease  is 
very  extensive,  or  in  which  excision  has  failed. 

Ankle  joint  disease  begins  most  frequently  in  the  synovial 
membrane,  next  in  the  astragalus;  it  may,  however,  commence  in 
the  tibia  or  fibula,  or  be  secondary  to  disease  of  the  tarsus  or  tendon 
sheaths.  The  usual  symptoms  of  joint  tuberculosis  are  present; 
the  foot  is  extended,  as  in  this  position  the  narrowest  part  of  the 
articulating  surface  of  the  astragalus  is  between  the  tibia  and 
fibula.     Antero-posterior    movements    are    markedly    limited,    but 


Fig.  247. — Thomas 
hip  splint.  Patten  on 
sound  limb. 


JOINTS 


487 


inversion  and  eversion  of  the  foot  may  be  made  if  the  subastragaloid 
and  mid-tarsal  joints  are  free  of  disease.  The  treatment  is  im- 
mobilization in  plaster-of-Paris  with  the  foot  at  a  right  angle  to 
the  leg.  Other  forms  of  conservative  treatment  are  also  of  service. 
In  the  presence  of  sinuses  or  disorganization  of  the  joint  erasion  or 
excision  should  be  performed.  The  disease  is  apt  to  invade  other 
tarsal  bones  besides  the  astragalus  and  to  extend  into  the  surround- 
ing soft  tissues;  in  these  cases  amputation  will  be  the  operation 
of  choice. 

Rheumatic  arthritis,  when  aaite,  is  characterized  by  fever, 
anemia,  Icucocytosis,  acid  and  sour  smelling 
sweats,  concentrated  highly  acid  urine,  and  by 
the  successive  involvement  of  a  number  of 
joints;  and  it  is  often  comphcated  by  sore  throat, 
pericarditis,  endocarditis,  or  pleurisy.  The  his- 
tory of  previous  attacks  is  often  obtained. 
There  is  nothing  characteristic  in  the  local 
symptoms  to  distinguish  it  from  infective  arthri- 
tis, indeed,  many  believe  it  to  be  infective  in 
origin,  and  even  incision  and  irrigation  of  the 
joints  have  been  recommended.  For  a  full  con- 
sideration of  this  subject  the  reader  is  referred 
to  a  book  on  practice  of  medicine,  it  being  neces- 
sary in  this  place  only  to  caution  against  a  too 
ready  diagnosis  of  rheumatism  without  a  careful 
investigation,  particularly  if  but  one  joint  is  l^eta^  plate 
involved. 

In  the  chronic  variety  the  history,  the  in 
volvement  of  several  joints,  the  presence  of  car-  *ended^b^^*^he^%Sip 
diac  lesions,  and  the  detection  of  rheumatic  over  the  opposite 
nodules  on  tendons  or  fascia,  or  about  joints,  will 
usually  lead  to  a  correct  diagnosis.  The  synovial  membranes  and 
the  ligaments  are  thickened  and  sometimes  the  cartilages  eroded; 
grating,  or  crepitus,  may  be  felt  on  moving  the  joint,  and  ankylosis 
occasionally  occurs. 

Gouty  arthritis  is  characterized  by  sudden  severe  pain,  which 
often  comes  on  during  the  night  and  attacks  the  smaller  joints, 
particularly  that  between  the  great  toe  and  its  metatarsal  bone. 
The  articulation  is  swollen,  the  skin  red,  shiny,  and  edematous, 
and  there  is  moderate  fever.  A  history  of  previous  attacks  may 
be  elicited,  and  other  evidences  of  gout,  e.g.,  tophi  (chalky  deposits  in 
or  around  the  joint),  dyspepsia,  and  atheroma  may  be  present.  For 
the  treatment  the  reader  is  referred  to  a  book  on  internal  medicine. 


Pig.  248. — Thomas 
knee  splint.  The 
is  several 
inches  below  the  foot. 
A  patten  is  worn  on 
the    sound     foot,    and 


488 


MANUAL   OF    SURGERY 


Osteoarthritis  {rheumatoid  arthritis,  arthritis  deformans,  rheu- 
matic gout,  malum  senile)  is  a  chronic  disease  of  joints  associated  with 
great  deformity.  The  cause  is  not  known.  Some  beheve  it  to  be 
of  nervous  origin  because  of  the  accompanying  trophic  lesions, 
others  that  it  is  due  to  microorganisms  because,  in  about  half 
the  cases,  it  is  preceded  by  some  infectious  disease.  It  is  more 
common  in  women,  and  is  sometimes  associated  with  disease  of  the 
uterus  or  ovaries.  Traumatism  is  often  a  factor  in  monarticular 
cases;  the  disease  is  not  very  uncommon  in  the  old  after  a  Colles' 
fracture,  or  after  a  fracture  of  the  neck  of  the  femur.  It  may  occur 
at  any  period  of  life,  but  is  most  frequent  after  middle  age.  The 
cartilages  become  eroded  and  the  ends  of  the  bones  exposed,  the 
synovial    membrane   and   the  ligaments  are   markedly   thickened, 

and  exostoses,  or  osteophytes, 
form  about  the  joint,  leading 
to  ankylosis  and  great  de- 
formity. Partial  dislocation 
may  occur. 

The  disease  begins  in 
several  ways:  i.  Heberden^s 
nodes  are  little  hard  knobs  de- 
veloping on  the  dorsal  sur- 
faces of  the  second  and  third 
phalanges,  subsequently  to 
recurring  attacks  ofin- 
eibow;  note  flammation  in  the  interphal- 
angeal  joints,  which  finally 
become  ankylosed.  They 
are  most  common  in  neurotic  women  between  the  ages  of  thirty 
and  forty,  and  are  incurable.  2.  General  progressive  osteroarthritis 
begins  as  an  acute  process  somewhat  resembling  rheumatism,  or 
more  commonly  in  a  chronic  manner.  In  the  latter  variety  the 
joints  of  the  hands  usually  swell  and  become  tender,  and  with 
the  subsidence  of  inflammation  they  creak,  becoming  more  and 
more  deformed  with  each  succeeding  attack.  Gradually  other 
joints  are  involved,  until  in  the  worst  cases  practically  every  arti- 
culation in  the  body  may  be  affected.  The  muscles  atrophy  and 
by  their  contractures  further  increase  the  deformity.  The  progress 
of  the  disease  is  very  slow,  and  although  no  remedy  is  known,  it 
may  be  spontaneously  arrested  at  any  stage.  3.  The  monarticular 
form  is  the  only  one  which  concerns  the  surgeon.  It  occurs  chiefly 
in  old  men  and  follows  injury.     In  the  hip  it  is  known  as  morbus 


Fig.     249. — Osteoarthiritis    of 
osteophytes  and  enormous  lips  on  the  ends  of 
the  bones.      (MouUin.) 


JOINTS  489 

coxce  senilis,  in  the  spine  as  spondylitis  deformans;  spondylosis 
ritizomelique,  or  ankylosis  of  the  spine,  hips,  and  shoulders  is  a  form 
of  osteoarthritis.  In  the  early  stage  there  are  pain,  stiffness,  and 
perhaps  a  little  swelUng  and  creaking  in  the  joint.  Later  motion 
is  less  free,  bony  crepitus  becomes  evident,  neighboring  muscles 
atrophy,  osteophytes  form,  and  finally  ankylosis  occurs.  Occa- 
sionally, however,  the  joint  becomes  loose  and  the  bones  displaced. 
The  diagnosis  is  made  by  the  chronic  nature  of  the  affection,  the 
absence  of  suppuration,  the  deformity  (lipping  of  the  ends  of  the 
bones  and  osteophytes — Fig.  249)  crepitus,  the  frequent  history 
of  injury,  and  the  advanced  age  of  the  patient.  The  prognosis  is 
unfavorable. 

The  treatment  is  unsatisfactory.  The  general  health  should  be 
improved,  colds  and  draughts  avoided,  and  perhaps  iodid  of  sodium 
or  arsenic  administered.  In  view  of  the  possible  bacterial  origin 
of  the  disease,  the  whole  body  should  be  reviewed  for  sources  of 
infection,  not  forgetting  the  nose,  accessory  sinuses,  ear,  teeth, 
tonsils,  rectum,  colon,  and  genitourinary  organs.  When  the  joints 
are  swollen  and  tender  they  should  be  treated  like  synovitis.  Dur- 
ing the  quiescent  period,  the  hot-air  apparatus,  stimulating  lini- 
ments, massage,  and  passive  motions  are  useful,  as  they  hinder 
the  development  of  ankylosis.  When  the  disease  is  limited  to  one 
joint,  e.g.,  the  temporomaxillary,  shoulder,  elbow,  or  knee,  excision 
or  arthroplasty  may  be  performed  if  the  function  of  the  articulation 
is  seriously  disturbed. 

Neuropathic  arthritis  resembles  osteoarthritis,  and  is  the  result 
of  disease  or  injury  of  the  central  or  peripheral  nervous  system. 
That  form  occurring  in  locomotor  ataxia  is  called  Charcot's  disease. 
The  joints  of  the  lower  extremity,  particularly  the  knee,  are  most 
frequently  affected.  As  the  result  of  a  slight  injury,  or  often  with- 
out such  history,  the  joint  rapidly  and  painlessly  swells,  and  in 
even  a  few  hours  may  be  dislocated,  or  so  freely  movable  that  it 
can  be  bent  in  any  direction.  The  disease  may,  however,  run  a 
chronic  course  and  end  in  ankylosis.  A  somewhat  similar  joint 
affection  occurs  in  syringomyelia,  but  the  joints  involved  are  usually 
those  of  the  upper  extremity,  and  suppuration  is  more  frequent 
than  in  Charcot's  disease.  Every  painless  osteoarthritis  should 
rouse  a  strong  suspicion  of  syringomyelia  or  tabes  dorsalis. 

The  treatment  of  neuropathic  arthritis  includes  that  of  the 
causative  disease.  In  some  forms  massage  and  passive  motions  are 
indicated,  but  in  Charcot's  disease,  if  there  is  a  tendency  towards 
ankylosis,  it  should  be   encouraged.     As  this  is  seldom  the  case 


490  MANUAL    OF    SURGERY 

some  form  of  support  will  usually  be  required.  Resection  has 
been  performed,  but  is  not  generally  regarded  with  favor.  If 
suppuration  or  extensive  disorganization  occurs,  amputation  is 
the  best  treatment. 

Neuralgia  of  joints  usually  depends  upon  some  local  or  con- 
stitutional cause,  although  cases  occur  in  which  neither  of  these  can 
be  found.  After  injury  loose  bodies,  adhesions,  or  small  areas  of 
inflammation  may  be  responsible.  It  may  be  due  to  disease  of  the 
central  or  peripheral  nervous  system,  or  be  reflect  from  disease  or  in- 
jury of  nerve  fibers  coming  from  the  same  trunk  that  supplies  the 
joint,  and  it  may  be  associated  with  gout,  rheumatism,  syphiHs, 
malaria,  neurasthenia,  or  hysteria.  Like  neuralgia  elsewhere,  the 
pain  is  paroxysmal.  The  treatment  is  that  of  the  causative  lesion, 
if  such  can  be  found;  other  cases  are  treated  as  neuralgia  elsewhere. 

Hysterical  joint  (neuromimesis)  is  characterized  by  pain  and 
tenderness,  hyperesthesia  or  anesthesia  of  the  overlying  skin, 
rigidity  of  the  joint,  muscular  atrophy  from  disuse,  and  absence  of 
local  heat  and  swelHng,  unless  these  be  present  from  the  use  of 
irritating  apphcations.  The  condition  is  most  frequent  in  the 
knee  and  hip,  usually  of  young  women.  Some  cases  follow  injury, 
others  arise  spontaneously.  The  diagnosis  is  made  by  carefully 
excluding  all  organic  disease,  and  by  finding  associated  symptoms  of 
hysteria.  The  joint  may  be  fixed  in  a  position  contrary  to  that 
usually  assumed  in  disease,  and  be  freely  movable  under  light 
anesthesia  or  when  the  patient's  attention  is  diverted.  The  position 
of  the  limb  may  vary,  sometimes  quite  suddenly.  The  treatment  is 
that  of  hysteria.  Electricity,  massage,  and  passive  motions  are  use- 
ful, but  may  do  harm  by  concentrating  the  patient's  attention  upon 
the  joint. 

Hemarthrosis  (effusion  of  blood  into  a  joint) ,  apart  from  injury 
may  be  due  to  a  number  of  causes  (see  spontaneous  hemorrhage). 
In  hemophiha,  following  a  sKght  injury  or  sometimes  spontaneously, 
a  joint  becomes  distended  with  blood,  which  may  gradually  be  ab- 
sorbed, leaving  the  joint  again  normal,  or  become  organized  and  lead 
to  adhesions  and  obhteration  of  the  joint.  The  history  is  the  most 
important  factor  in  diagnosis.  The  treatment  is  immobilization 
and  compression.  Massage  and  passive  motion  may  be  used  with 
caution  in  the  later  stages.  Under  no  circumstances  should  the 
joint  be  aspirated  or  opened,  as  such  treatment  migh  be  followed  by 
uncontrollable  hemorrhage. 

Loose  bodies  in  joints  {joint  mice)  consist  of  fibrin,  fatty  tissue 
fibrous  tissue,  cartillage,  or  bone.     Those  made  of  fibrin  are  usually 


JOINTS  491 

small  and  numerous,  and  are  best  seen  in  tuberculosis  of  joints 
bursas,  or  tendon  sheaths  {rice  bodies).  Occasionally  they  are  due 
to  other  causes,  e.g.,  a  small  foreign  body,  blood  clot,  or  detached 
synovial  villus,  around  which  the  fibrin  collects.  Such  loose  bodies 
frequently  become  fibrous.  Bodies  which  are  at  first  pedunculated 
<and  afterwards  become  loose  by  rupture  of  the  pedicle,  may  be  fatty 
(in  lipoma  arboresccns),  fibrous,  cartilaginous,  or  bony,  according 
to  the  tissue  from  which  they  spring;  they  may  be  also  neoplasms, 
or  result  from  hypertrophy  of  synovial  viUi,  desiccation  of  cartilage, 
or  detachment  of  osteophytes  in  chronic  arthritis.  The  most 
frequent  cause,  however,  is  injury,  a  portion  of  bone,  or  more  fre- 
quently cartilage,  being  detached  from  the  articular  surface,  usually 
the  internal  condyle  of  the  knee,  which  is  the  joint  generally  affected. 
Though  even  completely  detached,  these  bodies  may  continue  to 
grow,  being  nourished  by, the  synovial  fluid. 

The  symptoms  are  severe  pain  and  temporary  locking  of  the 
joint,  followed  by  subacute  synovitis,  and  caused  by  the  loose  body 
lodging  between  the  ends  of  the  bones  or  in  a  synovial  recess.  These 
attacks  recur  from  time  to  time,  and  owing  to  repeated  distention, 
the  ligaments  may  become  relaxed  and  the  joint  weakened.  Loose 
bodies  may  sometimes  by  palpated,  but  are  very  elusive,  hence  the 
name  joint  mice.  If  bony  in  nature  they  may  be  detected  by  the  X- 
ray.  The  symptoms  closely  resemble  those  of  a  dislocated  semi- 
lunar cartilage,  but  in  loose  bodies  the  locking  of  the  joint  is  usually 
of  brief  duration,  and  there  is  no  marked  tenderness  over  the  site 
of  the  semilunar  cartilage. 

The  treatment  is  removal  by  a  small  incision  directly  over  the 
loose  body,  which  should  be  held,  whenever  possible,  by  the  fingers  of 
the  other  hand,  or,  better,  transfixed  by  a  needle  before  the  patient 
is  anesthetized,  otherwise  the  body  may  elude  even  the  most  careful 
search  after  the  joint  is  opened.  Some  surgeons  employ  a  local 
anesthetic,  thus  enabling  the  patient  to  bring  the  loose  body  to  the 
surface,  in  case  it  escapes  the  operator.  The  joint  should  be  explored 
for  other  loose  bodies,  closed  with  sutures,  and  immobilized  for  a 
week  or  two. 

Ankylosis  is  rigidity  or  immobility  of  a  joint.  It  may  be  true 
or  false. 

In  true,  or  intraarticular  ankylosis,  the  joint  surfaces  are  united 
by  fibrous  tissue,  cartilage,  or  bone.  Fibrous  ankylosis  is  usually 
incomplete,  unless  the  entire  joint  is  obUterated  by  short  bands  of 
strong  fibrous  tissue;  the  latter  may  be  dift'erentiated  from  bony 
ankylosis  by  the  X-ray,  by  pain  on  attempts  to  move  the  joint,  and 


492  MANUAL    OF    SURGERY 

by  subsequent  signs  of  inflammation,  if  these  attempts  have  been 
very  forcible.  Cartilaginous  or  bony  ankylosis  is  complete  (no 
motion),  except  in  some  cases  of  ossification  of  the  periarticular 
structures,  and  in  some  cases  caused  by  the  interlocking  of  osteo- 
phytes in  osteoarthritis.  The  causes  of  true  ankylosis  are  the  various 
forms  of  synovitis  and  arthritis.  It  may  be  caused  also  by  an  unre- 
duced dislocation  or  fracture,  or  by  disease,  e.g.,  caries,  which  alters 
the  shape  of  the  ends  of  the  bones  so  that  they  no  longer  fit  each 
other  {ankylosis  of  deformity).  Simple  immobilization  of  the  large 
joints  without  inflammation  does  not  lead  to  ankylosis,  although  if 
prolonged  it  may  cause  stiffness  owing  to  the  atrophy  of  the  peri- 
articular structures.  The  effects  of  ankylosis  vary  with  its  degree, 
the  angle  of  fixation  (a  straight  knee  and  an  elbow  bent  to  a  right 
angle  are  much  more  useful  than  a  bent  knee  and  a  straight  elbow), 
the  joint  affected  (e.g.,  in  the  shoulder  ankylosis  is  compensated  for 
by  movements  of  the  clavicle  and  scapula),  and  the  amount  of 
amount  of  atrophy  of  the  bones  and  soft  parts ;  in  children  there  may 
be  stunting  of  the  growth  of  a  limb. 

The  treatment  is  prophylactic  and  curative.  The  prophylactic 
treatment  consists  in  Kmiting  effusions  or  inflammatory  exudates, 
which  by  organization  cause  ankylosis ;  and  in  preventing  the  union 
ot  synovial  surfaces  by  early  passive  movements.  If  ankylosis  is 
inevitable  the  joint  should  be  placed  in  a  position  which  will  be  of 
most  service  to  the  patient.  In  incomplete  ankylosis  due  to  limited 
synovial  adhesions,  daily  attempts  to  move  the  joint,  without  causing 
intolerable  pain,  will  stretch  or  break  the  adhesions  and  result  in 
cure.  If  the  adhesions  are  more  extensive,  the  joint  may  be  forcibly 
moved  while  the  patient  is  under  a  general  anesthetic.  This  treat- 
ment causes  a  recurrence  of  the  inflammation,  and  the  joint  must  be 
immobilized  until  it  has  subsided,  when  massage  and  passive  motions 
are  begun.  In  long  standing  csises  forcibly  breaking  adhesions  under 
an  anesthetic  occasionally  results  in  fracture  of  atrophied  bone,  fat 
embolism,  or  tearing  of  shortened  blood  vessels,  nerves,  skin,  or  other 
soft  tissues.  It  should  not  be  attempted  after  the  subsidence  of  a 
tuberculous  arthritis  for  fear  of  recurrence.  Other  cases  of  ankylosis 
which  should  be  left  alone  are  those  occurring  in  patients  (the  old, 
feeble,  etc.)  whose  general  condition  forbids  operation  or  painful 
manipulations,  particulary  when  the  joint  is  in  a  useful  position. 

Electricity  and  massage  are  beneficial  in  maintaining  nutrition  and 
preventing  atrophy  of  muscles.  If  the  adhesions  are  very  extensive, 
forcibly  breaking  them  under  an  anesthetic  wiU  be  followed  by  so 
much  inflammatory  reaction  that  they  will  reform  before  passive 


JOINTS  493 

motions  can  be  started.  In  these  cases  as  well  as  in  complete  ankylo- 
sis, recovery  can  be  secured  only  by  operation,  which  always  should 
be  undertaken  if  the  joint  be  fixed  at  a  vicious  angle.  Osteotomy  has 
been  employed,  chiefly  in  ankylosis  of  the  hip  and  knee,  to  straighten 
a  limb  that  is  fixed  at  an  inconvenient  angle.  In  ankylosis  of  the  hip 
the  femur  is  cut  through  the  neck  or  immediately  below  the  tro- 
chanter, after  making  an  incision  from  just  below  the  anterior 
superior  spine  vertically  downwards  for  three  or  more  inches.  Ad- 
ams' subcutaneous  osteotomy  of  the  neck  of  the  femur  is  performed  by 
introducing  a  knife  midway  between  the  trochanter  and  the  anterior 
superior  spine  of  the  ilium,  and  pushing  it  inwards  until  it  reaches 
the  neck  of  the  bone.  An  Adams'  saw  is  then  introduced  and  the 
neck  of  the  bone  divided.  The  limb  is  straightened  and  the  bone 
reunites.  In  ankylosis  of  the  knee  the  bone  is  divided  above  the 
joint  in  much  the  same  way  as  for  genu  valgum.  Excision  may  be 
performed,  e.g.,  at  the  elbow  to  obtain  a  movable  joint,  or,  e.g.,  at  the 
knee  when  it  is  bent,  to  place  the  limb,  although  still  rigid,  in  a  more 
useful  position.  Arthrolysis  is  exposure  of  the  joint  by  an  incision 
suitable  for  resection,  and  division  or  removal  of  all  adhesions,  bony 
prominences,  etc.,  which. interfere  with  movement.  After  operations 
of  this  character  the  joint  may  be  filled  with  sterile  olive  oil  or  hquid 
vaseline  to  prevent  the  reformation  of  adhesions.  Nonabsorbable 
foreign  bodies,  such  as  silver,  zinc,  celluloid,  rubber,  etc.,  have  been 
placed  between  the  ends  of  the  bones  to  maintain  mobility,  but  are 
almost  uniformly  unsuccessful,  in  that  the  foreign  substance  is 
usually  discharged  and  the  ankylosis  recurs.  Absorbable  sub- 
stances, e.g.,  magnesium,  Cargile  membrane,  chromicized  pig's 
bladder,  decalcified  bone,  are  objectionable  because  they  are  ab- 
sorbed, thus  permitting  the  osseous  surfaces  again  to  come  in  contact. 
Fortunately  nonforeign  and  nonabsorbable  material  (cartilage, 
muscle,  fascia)  can  always  be  obtained  from  the  patient.  At  the 
present  time  the  best  prospects  for  a  new  and  movable  joint  (near- 
throsis) seem  to  be  offered  by  arthroplasty,  which,  thanks  to  the  ac- 
tivity of  Huguier,  Murphy,  and  others,  has  been  developed  to  an 
advanced  degree  of  perfection.  The  operation  proceeds  as  in  ar- 
throlysis, but  the  ends  of  the  bones  are  removed  or  pared  down,  and 
new  articular  surfaces  fashioned  after  the  patern  of  a  normal  joint 
(Figs.  250,  251).  A  pedunculated  flap  of  fat  and  fascia  from  the 
neighborhood  of  the  joint,  or  a  free  transplant  of  the  same  material 
from  a  distance  (e.g.,  from  the  fascia  lata  to  the  elbow)  is  then  fixed 
with  catgut  sutures  between  the  bony  surfaces.  Lexer  has  resected 
the  knee  and  successfully  transplanted  to  its  place  the  knee  joint  of  a 


494 


MANUAL    OF    SURGERY 


recently  amputated  limb.     Buchmann  transplanted  the  first  meta- 
tarso  phalangeal  joint  to  the  elbow  and  obtained  a  good  result. 


Fig.   250. — Complete  ankylosis  of  the  elbow. 


Fig.  251. — Same  as  Pig.  250,  after  arthroplasty,  with  the  interposition  of  a  free  trans- 
plant of  fascia  lata. 

Weglowski  secured  a  movable  elbow  by  the  interposition  of  the  outer 
surfaces  of  the  sixth  and  seventh  costal  cartilages. 

False  ankylosis  is  caused  by  extraarticular  lesions,  such  as  cicatrices, 
shortening  of   muscles,    adhesions  of  tendons,  and  contraction  of 


JOINTS  495 

fascia;  it  may  be  bony  as  the  result  of  ossification  of  periarticular 
inflammatory  librous  tissue  or  of  muscles  (myositis  ossificans) 
False  ankylosis  is  treated  according  to  the  cause;  it  may  require 
excision  of  a  cicatrix;  tenotomy  or  tenoplasty;  myotomy  myomec- 
tomy, or  myoplasty;  removal  of  areas  of  ossification,  etc.  It  should 
be  recalled  that  any  of  these  operations  may  be  needed  to  assist 
also  in  the  cure  of  a  true  ankylosis. 

Arthrodesis  is  just  opposite  of  arthrolysis,  i.e.,  the  surgeon  at- 
tempts to  secure  ankylosis  in  a  flail  joint,  such  as  may  follow  paraly- 
sis. The  joint  is  opened,  either  arthectomy  or  excision  performed, 
and  the  bones  fastened  together  with  wire  or  nails.  In  performing 
arthrodesis  of  the  ankle  Lexer  advises  boring  a  hole  up  through  the 
OS  calcis,  astragalus,  and  lower  end  of  the  tibia,  and  driving  into  this 
hole  an  autoplastic  bone  graft. 

In  erasion,  or  arthrectomy,  the  joint  is  opened  by  an  incision 
suitable  for  resection,  and  the  diseased  tissues  (usually  tuberculous) 
arlone  removed  by  scissors  and  forceps,  or  by  curette.  When  appli- 
cable, erasion  is  to  be  preferred  to  resection,  since  it  causes  neither 
immediate  shortening  nor  subsequent  interference  with  the  growth 
of  the  limb. 

EXCISION  OF  JOINTS 

Excision,  or  resection,  of  a  joint,  i.e.,  of  the  articulating  ends  of 
the  bones  with  the  cartilages  and  synovial  membrane,  is  performed 
to  remove  an  articulation  destroyed  by  injury  or  disease  (usually 
tuberculosis),  thus  .avoiding  amputation,  or  to  render  a  Umb  more 
useful,  e.g.,  in  irreducible  luxations  or  other  forms  of  ankylosis. 
There  is,  of  course,  immediate  shortening  of  the  limb,  and  in  youth, 
if  an  entire  epiphysis  is  removed,  interference  with  subsequent 
growth,  hence  resection  of  joints,  especially  those  of  the  lower 
extremity,  in  which  the  greatest  growth  takes  place  and  in  which 
shortening  causes  the  greatest  inconvenience,  should  be  avoided 
whenever  possible.  There  are  two  general  methods  of  excision. 
The  subperiosteal,  or  conservative,  in  which  the  periosteum,  joint 
capsule,  and  attached  ligaments  and  tendons  are  saved,  is  the  ideal 
operation,  as  bone  may  be  reformed  from  the  periosteum,  and  move- 
ments of  the  joint  preserved  by  the  muscular  attachments.  It  is 
rarely  apphcable,  however,  because  these  structures  are  usually 
involved,  and  in  certain  joints,  notably  the  elbow,  new  bone  might 
interfere  with  free  motion.  In  the  radical  method  the  periosteum 
is  sacrificed.  The  incisions  should  be  so  made  as  to  enter  the  joint 
by  the  shortest  way  with  a  minimum  amount  of  injury  to  the  sur- 


496  MANUAL    OF    SURGERY 

rounding  tissues.     Drainage  with  a  rubber  tube  or  strands  of  silk- 
worm gut  is  almost  invariably  required. 

The  shoulder  joint  may  be  excised  through  an  anterior  oblique 
incision  three  or  four  inches  in  length;  extending  from  the 
coracoid  process  downward  and  outward  along  the  anterior  border 
of  the  deltoid  muscle,  the  patient  being  supine,  close  to  the  edge  of 
the  table,  and  the  shoulders  raised.  The  pectoro-deltoid  groove  is 
opened,  the  cephalic  vein  and  the  pectoral  muscles  retracted  inward 
and  the  deltoid  outward,  thus  uncovering  the  biceps  tendon,  to  the 
outer  side  of  which  the  capsule  of  the  joint  is  incised.  After  depress- 
ing the  elbow  and  rotating  the  humerus  inward,  the  supra-  and  infra- 
spinatus and  teres  minor  are  separated  from  the  greater  tuberosity, 
and  the  subscapularis  from  the  lesser  tuberosity  after  rotating  the 
bone  outward.  Flexing  the  elbow  relaxes  the  tendon  of  the  biceps 
which  is  then  displaced  inward,  and  the  head  of  the  bone  delivered 
through  the  wound  and  divided  with  a  saw.  If  the  glenoid  cavity  is 
involved,  the  diseased  bone  is  removed  with  a  curette,  or  as  a  seques- 
trum. The  arm  is  bound  to  the  chest  over  an  axillary  pad,  to  pre- 
vent displacement  of  the  end  of  the  humerus  under  the  coracoid. 
Passive  motions  are  begun  as  soon  as  the  stitches  have  been  removed. 

The  elbow  joint  (Fig.  568)  may  be  resected  through  a  posterior 
median  incision  (Langenbeck),  about  four  inches  in  length,  with  the 
tip  of  the  olecranon  process  at  its  middle,  the  arm  lying  across  the 
patient's  body.  The  periosteum  and  the  inner  half  of  the  triceps 
tendon  are  separated  from  the  ulna  and  olecranon  and  pushed 
inwards  with  the  ulnar  nerve,  then  the  internal  lateral  ligament  and 
the  common  origin  of  the  flexor  muscles  separated  from  the  inner 
condyle.  The  periosteum,  outer  half  of  the  triceps  tendon,  anconeus, 
external  lateral  ligament,  extensors  of  the  forearm,  and  supinator 
brevis  are  next  scraped  from  the  bone  on  the  outer  side,  and,  after 
flexing  the  forearm,  the  ends  of  the  bones  delivered  through  the 
wound  and  removed  with  a  saw.  The  forearm  is  placed  on  an 
internal  angular  splint  for  a  week  or  ten  days,  after  which  daily 
passive  motions  are  made. 

Of  all  excisions  that  of  the  wrist  joint  is  the  least  satisfactory. 
The  operation  is  difficult  and  tedious,  and  so  much  of  the  bony 
structures  usually  have  to  be  removed  that  the  hand  is  often  useless 
afterwards.  The  simplest  method  is  that  of  Langenbeck.  A 
straight  dorsal  incision  is  made  from  the  middle  of  the  metacarpal 
bone  of  the  index  finger  to  the  middle  of,  and  three-fourths  of  an 
inch  above,  the  lower  extremity  of  the  radius.  The  incision  passes 
along  the  radial  side  of  the  tendon  of  the  extensor  indicis.     The  ten- 


JOINTS  497 

dons  of  the  index  linger  are  retracted  to  the  ulnar  side  and  the  lower 
border  of  the  annular  ligament  divided.  The  fibrous  sheaths  of  the 
extensor  tendons,  the  insertion  of  the  supinator  longus,  the  annular 
and  capsular  ligaments,  and  the  periosteum  are  separated  from  the 
end  of  the  radius,  and  the  tendons,  ligaments,  and  periosteum  from 
the  ulna.  Flexing  the  hand  opens  the  radiocarpal  joint  and  facili- 
tates excision  of  the  first  row  of  carpal  bones.  It  may  be  necessary 
to  remove  those  of  the  second  row  and  even  the  bases  of  the  meta- 
carpal bones.  The  lower  ends  of  the  radius  and  ulna  are  next 
delivered  and  divided  with  a  saw\  If  the  tendons  of  the  extensor 
radialis  longior  and  brevior  are  in  the  way,  they  may  be  divided  and 
later  sutured.  A  straight  splint  is  applied  with  the  forearm  midway 
between  pronation  and  supination.  The  fingers  should  be  flexed 
and  extended  daily,  beginning  on  the  second  or  third  day,  but  the 
wrist  should  remain  fixed  until  healing  is  complete;  indeed  in  some 
cases  a  flail  joint  results  and  a  permanent  support  is  needed. 

The  hip  joint  may  be  entered  from  three  aspects,  anteriorly 
through  the  straight  incision  of  Barker,  laterally  through  a  curved 
(White)  or  straight  (Langenbeck)  incision,  and  posteriorly  through 
the  angular  incision  of  Kocher.  With  the  anterior  incision  no  mus- 
cular structures  are  divided  and  very  little  damage  is  done  to  the 
surrounding  tissues,  but  the  joint  is  poorly  exposed  at  the  bottom  of 
a  deep  wound  which  is  not  well  situated  for  subsequent  drainage. 
The  lateral  and  posterior  incisions  necessitate  the  cutting  of  muscles 
and  inflict  greater  damage  on  the  tissues,  but  they  render  the  joint 
more  accessible  and  facilitate  drainage.  The  anterior  incision  ex- 
tends from  one-half  inch  below  the  anterior  superior  spine  of  the 
ilium  downward  and  sHghtly  inward  for  three  or  four  inches.  The 
joint  is  exposed  by  retracting  the  tensor  vaginae  femoris  and  glutei 
outwards,  the  sartorius  and  rectus  inwards.  Branches  of  the  cir- 
cumflex artery  are  encountered  and  ligated.  The  joint  capsule, 
cotyloid  ligament,  and  periosteum  of  the  femur  are  incised  in  the  line 
of  the  wound,  and  as  air  enters  the  joint,  the  articulating  surfaces  of 
the  bones  may  be  separated  and  the  ligamentum  teres  cut.  The 
periosteum  w4th  the  attatched  muscles  is  then  separated  from  the 
greater  tuberosity,  and  the  bone  cut  with  an  Adams'  or  a  chain  saw, 
or  with  a  chisel.  The  line  of  division  may  be  above  or  below  the 
greater  trochanter.  The  acetabulum  is  curetted,  and  if  drainage  be 
necessary,  a  counteropening  made  posteriorly. 

Langenheck  's  external  incision  extends  from  a  point  three  inches 
above  the  upper  border  of  the  great  trochanter  down  over  that  pro- 
minence for  four  or  five  inches  in  the  long  axis  of  the  femur,  the  patient 

32 


49^  MANUAL    OF    SURGERY 

lying  upon  the  sound  side  with  the  thigh  flexed  at  an  angle  of  forty- 
five  degrees.  The  skin  and  fascia  are  divided  and  the  fibers  of  the 
gluteus  maximus  separated,  thus  exposing  the  gluteus  medius  and 
pyriformis,  which  are  separated  with  retractors.  The  capsule  of  the 
joint  and  periosteum  over  the  greater  trochanter  are  then  incised  in 
the  line  of  the  wound,  an  additional  transverse  incision  being  made  if 
necessary,  and  the  periosteum  and  muscles  elevated.  After  cutting 
the  cotyloid  and  round  Kgaments,  the  thigh  is  adducted  and  rotated 
outward,  thus  forcing  the  head  of  the  bone  through  the  wound.  The 
bone  is  usually  divided  below  the  great  trochanter,  as  its  removal,  if 
the  periosteum  and  muscles  are  intact,  does  not  interfere  with  sub- 
sequent motion;  if  permitted  to  remain  it  interferes  with  drainage 
and  may  become  diseased.  A  Buck's  extension  is  applied  to  the  leg 
which,  is  supported  laterally  by  sand  bags.  The  cavity  becomes 
filled    with    fibrous    tissue    which    permits    limited    motion. 

In  the  knee  joint  (Fig.  582)  fixation  and  not  motion  is  desired 
after  resection.  An  anterior  semilunar  incision  is  made  from  the 
posterior  and  upper  border  of  one  condyle  to  the  other,  the  convexity 
closely  approaching  the  insertion  of  the  ligamentum  patellae.  After 
flexing  the  leg  to  a  right  angle,  the  superficial  tissues,  hgamentum 
patellae,  and  the  anterior,  lateral,  capsular,  and  crucial  ligaments 
are  divided  in  turn.  Carefully  protecting  the  popliteal  structures, 
the  condyles  of  the  femur  are  freed,  then  cut  in  a  plane  at  right 
angles  to  the  long  axis  of  the  bone.  The  head  of  the  tibia  is  similarly 
exposed  by  retraction  of  the  tissues,  pushed  forward,  and  the  arti- 
culating surface  shaved  oft".  The  patella  and  all  of  the  infected 
synovial  membrane  and  bursae  are  then  removed,  and  a  rubber  tube 
placed  behind  the  bones,  to  emerge  at  each  angle  of  the  wound.  The 
bones  may  be  fixed  together  with  a  bone  graft,  wire,  nails,  by  sutur- 
ing the  ligaments,  or  merely  by  a  fixed  dressing  (see  Fig.  54).  The 
splint  or  plaster  cast  should  be  worn  for  at  least  eight  weeks. 

The  ankle  joint  is  seldom  resected,  as  a  modern  artificial  leg  gives 
a  more  useful  limb  than  the  ankylosed  and  fixed  joint  usually  follow- 
ing excision.  In  the  Langenbeck  operation,  a  hook-shaped  incision 
is  first  made  around  the  lower  end  of  the  fibula;  starting  three  inches 
above  the  tip  it  follows  the  posterior  border,  curves  around  the 
external  malleolus,  and  passes  upward  on  the  anterior  border  for  one 
inch.  The  periosteum  and  overlying  tissues  are  separated  from  the 
bone,  which  is  divided  at  the  upper  end  of  the  wound  and  drawn 
outward,  when  the  ligaments  attached  to  the  lower  end  are  cut.  A 
second  incision,  one  and  one-half  inches  in  length,  curves  around  the 
internal  malleolus,  and  this  is  joined  by  a  vertical  cut,  two  inches 


JOINTS  499 

long,  made  in  the  median  line  of  the  tibia  (anchor-shaped  incision). 
The  bone  is  freed  and  removed  as  on  the  outer  side.  A  part  or  the 
whole  of  the  astragalus  may  be  removed  through  either  wound, 
preferably  the  inner.  Another  method  is  to  make  a  transverse 
incision  across  the  front  of  the  joint  connecting  both  malleoli.  The 
tendons  and  anterior  tibial  nerve  are  sutured  at  the  completion  of  the 
operation.  A  fenestrated  plaster  cast  is  apphed  with  the  foot  at  a 
right  angle  with  the  leg. 


CHAPTER  XXI 

HEAD 

THE  SCALP 

Contusions  of  the  scalp  require  special  mention  only  because  of 
the  danger  of  associated  injury  to  the  brain,  for  the  symptoms  of 
which  a  careful  examination  should  always  be  made.  They  cause  an 
effusion  of  blood  into  the  tissues  which  may  amount  to  a  hematoma. 
In  new-born  children  the  effusion  due  to  pressure  around  the  present- 
ing part  is  called  caput  sticcedanemn.  Hematoma  may  be  (i)  sub- 
cutaneous. (2)  subaponeurotic,  (3)  subpericranial.  (i)  Subcutaneous 
hematoma,  i.e.,  in  the  cellular  tissue  between  the  skin  and  the  apon- 
eurosis of  the  occipitofrontaHs,  is  the  result  of  a  direct  injury,  and  is 
small,  sharply  locahzed,  movable,  and  often  associated  with  ecchy- 
mosis.  (2)  Subaponeurotic  hematoma,  e..i.  in  the  loose  tissue  between 
the  occipitofrontahs  and  the  pericranium,  may  be  caused  by  a  glanc- 
ing blow  which  shdes  the  scalp  beyond  its  normal  range  of  movability, 
or  by  a  direct  injury,  in  which  event  the  bleeding  usually  proceeds 
from  a  fracture  of  the  skull.  It  appears  as  a  large  fluctuating  swell- 
ing, often  reaching  from  the  eyes  to  the  occiput.  (3)  Suh pericranial 
hematoma  {cephalhematoma)  is  due  to  tearing  of  the  vessels  running 
from  the  pericranium  to  the  bone,  as  the  result  of  slipping  of  the 
pericranium  on  the  skull  during  birth,  or  as  the  result  of  a  glancing 
blow  in  childhood.  It  probably  never  occurs  in  adults,  in  whom  the 
pericranium  is  much  less  vascular,  because  growth  is  finished,  and  in 
whom  the  scalp  is  much  less  movable.  The  swelling  covers  a  part 
or  the  whole  of  one  bone,  usually  the  parietal,  but  does  not  extend 
beyond  the  margins  of  the  bone,  owing  to  the  attachments  of  the 
pericranium  at  the  sutures.  It  is  not  associated  with  ecchymosis, 
and  is  immovable,  soft  in  the  center,  and,  owing  to  a  deposition  of 
fibrin,  hard  at  the  margin,  hence  may  be  mistaken  for  a  fracture  of 
the  skull.  The  margin,  however,  is  regular,  pits  on  pressure  (some- 
times with  moist  crepitation),  and  is  above  the  contour  of  the  head. 
In  late  cases  deception  is  still  more  easy,  as  the  edges  may  ossify  and 
slope  upwards  so  gradually  that  one  cannot  be  sure  whether  they  are 
above  the  normal  contour  of  the  skull  or  not.  In  one  of  our  cases 
there  was  parchment  crepitation  on  palpating  the  elevated  peri- 
iosteum.  Here  must  be  mentioned  also  the  possibihty  of  mistaking 
a   cephalhematoma   for   a   spurious   meningocele    {vide  infra).     A 


HEAD  501 

skiagram  may,  of  course,  demonstrate  a  fracture,  but  if  it  is  negative 
and  one  is  still  in  doubt,  particularly  if  there  are  symptoms  of  intra- 
cranial mischief,  the  j)arts  should  be  incised  and  carefully  explored. 
The  treatment  of  contusions  and  hematomata  of  the  scalp  is  that  of 
similar  lesions  in  other  parts  of  the  body. 

"Wounds  of  the  scalp  always  require  a  careful  examination  for 
fracture  of  the  skull  or,  in  the  abscence  of  this,  for  signs  of  concussion 
or  intracranial  hemorrhage.  It  should  be  recalled  also  that  lacer- 
tion  of  the  scalp  may  have  been  the  result  of  a  fall  caused  by  a  seri- 
ous constitutional  disease  or  the  taking  of  a  poison.  If  the  wound  is 
too  small  for  exploration  and  there  are  any  suspicious  symptoms,  it 
should  be  enlarged.  A  slit  in  the  pericranium  may  feel  like  a  frac- 
ture, but  all  doubt  is  dispelled  by  careful  inspection.  A  suture  will 
not  be  taken  for  a  fracture  if  one  recalls  the  situation  of  the  suture 
and  observes  that  it  does  not  bleed.  In  the  temporal  region  a 
wound  of  the  fascia  may  resemble  a  fracture,  but  the  supposed  cere- 
bral tissue  (temporal  muscle)  will  harden  when  the  patient  shuts  his 
jaw.  A  superficial  scalp  wound,  even  if  infected,  is  rarely  a  serious 
matter;  if,  however,  the  loose  subaponeurotic  tissue  has  been  opened 
and  infected,  suppuration  may  spread  to  the  attachments  of  this 
structure,  i.e.,  to  the  eyebrows,  zygoma,  and  superior  curved  line 
of  the  occipital  bone.  A  flap  of  scalp,  even  of  the  largest  size,  retains 
its  vitaHty  owing  to  the  fact  that  the  vessels  run  in  the  scalp  and  do 
not  come  from  the  subjacent  structures.  The  treatment  is  that  of 
wounds  elsewhere. 

Traumatic  or  supurious  meningocle  is  a  collection  of  cerebro- 
spinal fluid  beneath  the  scalp  following  a  fracture,  usually  in  a  child. 
It  pulsates,  has  an  impulse  on  coughing,  and  may  be  reducible.  The 
treatment  in  the  same  as  that  of  meningocele. 

Abscess  of  the  scalp  may  be  due  to  infection  from  the  exterior 
or  to  disease  of  the  cranial  bones.  Suppuration  is  limited  in  the  same 
way  as  extravasation  in  hematoma.  In  the  subaponeurotic  form 
the  abscess  is  bounded  only  by  the  attachments  of  the  aponeurosis 
of  the  occipito  frontalis.  In  these  cases  the  constitutional  symptoms 
are  severe  and  the  infection  may  spread  to  the  intracranial  structures. 
Incision  should  be  made  above  the  zygoma  on  each  side,  above  the 
superior  curved  line  of  the  occipital  bone  behind,  and  if  necessary, 
above  the  brows  in  front. 

Tumors  (using  the  term  in  its  broadest  sense)  springing  from  the 
scalp  or  the  subjacent  structures  are  pulsating  or  non-pulsating. 
The  pulsating  tumors  include  ordinary  aneurysm,  arteriovenous 
aneurysm,  arterial  varix,  angioma,  circoid  aneurysm,   sarcoma  (of 


502 


MANUAL    OF    SURGERY 


bone  or  meninges),  meningocele  (true  and  spurious),  encephalocele 
hydrencephalocele,  hernia  cerebri,  and  other  tumors  if  situated  ove 
an  open  fontanelle.  Among  the  non-pulsating  Inmors  are  papihom 
(wart),  horns,  moles,  epithelioma,  fibroma  (when  diffuse  and  involv 
ing  a  large  part  of  the  scalp  it  is  known  as  pachydermatocele),  sar- 
coma, sebaceous  cyst,  dermoid  cyst,  subaponeurotic  lipoma,  gumma, 
syphilitic  nodes,  exostosis,  pneumatocele,  abscess  and  hematoma. 
The  congenital  tumors  are  hematoma,   angioma,  meningocele,  en- 


FiG.  252. — Skull  showing  the  points  named  by  Broca  As,  asterion  (junction  of  the 
occipital,  parietal,  and  temporal  bones) ;  Basion,  middle  of  anterior  wall  of  foramen 
magnum;  B,  bregma  (junction  of  the  sagittal  and  coronal  sutures) ;  G,  ophryon  (on  a  level 
with  the  superior  border  of  the  eyebrows,  and  corresponding  nearly  to  the  glabella,  the 
snwDOth  swelling  between  the  eyebrows);  g,  gonion  (angle  of  the  lower  jaw);  /,  inion 
(external  occipital  protuberance);  Z,  lambda  (junction  of  sagittal  and  lambdoidal 
sutures);  A'',  nasion  (junction  of  the  nasal  and  frontal);  Ob,  obelion  (the  sagittal  suture 
between  the  parietal  foramina) ;  P,  pterion  (point  of  junction  of  great  wing  of  sphenoid 
and  the  frontal,  parietal,  and  squamous  bones.  This  may  be  H-shaped  or  K-shaped,  or 
"retoume,"  in  which  the  frontal  and  temporal  just  touch);  S,  stephanion  (or,  better, 
the  superior  stephanion,  (intersection  of  ridge  for  temporal  fascia  and  coronal  suture) ; 
S',  inferior  stephanion  (intersection  of  ridge  for  temporal  muscle  and  coronal  suttire). 
(American  Text-book  of  Surgery.) 


cephalocele,  hydrencephalocele,  and  dermoid  cyst.  The  last  is 
usually  situated  at  the  outer  canthus  of  the  eye  or  root  of  the  nose 
and  sometimes  communicates  with  the  interior  of  the  skull  through 
a  congenital  opening  in  the  bone,  hence  may  be  mistaken  for  a  men- 
ingocele. Most  of  these  aff'ections  have  already  been  described,  the 
rest  will  be  described  below. 

Craniocerebral  Topography  and  Cerebral  Localization. — Figure 
252  shows  Broca 's  points  marked  on  the  skull.      The  longitudinal 


HEAD 


503 


fissure,  containing  the  lonj^jtudinal  sinus,  underlies  a  line  drawn  from 
the  glabella  to  the  inion  and  passing  along  the  sagittal  suture.  The 
fissure  of  Bichal  separates  the  cerebrum  from  the  cerebellum,  contains 
the  lateral  sinus,  and  is  indicated  by  a  line  drawn  from  the  inion  to 
the  external  auditory  meatus.  The  fissure  of  Sylvius  runs  from  a 
point  one  and  a  c^uarter  inches  behind  the  external  angular  process 
of  the  frontal  bone  and  the  same  distance  above  the  zygoma,  to 
a  point  three-fourths  of  an  inch  below 
the  most  prominent  part  of  the  parietal 
eminence.  The  main  fissure  corresponds 
to  the  first  three-fourths  of  an  inch  of  this 
line,  and  the  horizontal  limb  to  the  remain- 
ing portion,  the  ascending  limb  passing  up- 
wards, parallel  to  the  coronal  suture,  for  one 
inch  from  the  junction  of  the  main  fissure 
and  the  horizontal  limb.  The  fissure  of 
Rolando  extends  from  one-half  inch  behind 
the  midpoint  between  the  glabella  and  the  inion,  downward  and 
forward  for  three  and  three-eighths  inches,  at  an  angle  of  67)-^  de- 
grees. This  angle  may  approximately  be  found  by  taking  a  square 
piece  of  paper  and  folding  one  corner  back  on  the  line  A  C  (Fig. 
253),  i.e.,  from  the  middle  of  the  side  D  B  to  the  corner  A.  The  side 
E  A  is  then  placed  in  the  middle  line  of  the  head,  and  the  line  A  C 
corresponds  to  the  fissure  of  Rolando,  the  angle  E  A  C  being  67H 


Fig.  253. 


Fig.   254. — Horsley's  cyrtometer. 

degrees.  Horsley's  cyrtometer  (Fig.  254)  is  an  instrument  for  mark- 
ing out  the  fissure  of  Rolando.  The  precentral  or  vertical  sulcus  (Fig. 
255)  lies  just  behind  and  parallel  to  the  coronal  suture,  or  one  con- 
volution (roughly  one  finger's  breadth)  in  front  of  the  fissure  of 
Rolando.  The  intraparietal  sulcus  begins  one  convolution  behind 
the  junction  of  the  middle  and  lower  thirds  of  the  fissure  of  Rolando 
passes  upward  midway  between  the  Rolandic  fissure  and  the  parietal 
eminence,  then  curves  backward  between  the  longitudinal  fissure 


504 


MANUAL   OF    SURGERY 


and  the  parietal  eminence  into  the  occipital  lobe.  The  supramar- 
ginal  convolution  lies  behind  the  intraparietal  fissure  and  curves  over 
the  extremity  of  the  fissure  of  Sylvius,  uniting  posteriorly  with  the 


Bregma 


Position  of  parietal 

eminence 


Pario-occipital 
Lambda 


'Fissure  of  bichat 


Fig.   255. — Diagram  showing  relations  to  the  skull  of  the  middle  meningeal  artery  (in 
red)  the  superior  longitudinal  and  lateral  sinuses  (in  blue),  and  the  principal  fissures. 

angular  convolution,  which  arches  over  the  extremity  of  the  superior 
temporal  fissure  (Fig.  257). 

Kronlein's  method  (Fig.  256)  of  craniocerebral  topography  is  as 
follows:     A  horizontal  line,  A  B,  is  drawn  through  the  lower  margin 

of  the  orbit  and  upper  margin  of  the  ex- 
ternal auditory  meatus.  Above  and 
parallel  with  this  is  a  second  hne,  C  D, 
on  a  level  with  the  upper  margin  of  the 
orbit.  Three  vertical  lines  are  now 
drawn,  the  first  passing  through  the 
middle  of  the  zygoma,  E  F,  the  second, 
G  H,  through  the  condyle  of  the  lower 
jaw,  and  the  third,  T  J,  through  the 
posterior  margin  of  the  mastoid  process. 
A  line  drawn  from  K  to  J  corresponds 
between  L  and  J  to  the  fissure  of  Rolando.  The  line  K  M.  which 
bisects  the  angle  J  K  N,  corresponds  to  the  horizontal  limb  of  the 
fissure  of  Sylvius.  If  this  line  is  continued  backward  to  the  middle 
line  of  the  head  (O)  it  indicates  approximately  the  situation  of  the 
parietooccipital  fissure.  K  and  N  are  the  points  to  trephine  for  the 
anterior  and  posterior  branches  of  the  middle  meningeal  artery. 
It  should  be  recalled  that  the  cerebral  centers  exhibit  exaltation 


Fig.    256. — Kronlein's  method   of 
craniocerebral  topography. 


HEAD 


505 


or  abolition  of  function  according  to  the  degree  of  disease  or  injury; 
thus  there  may  be  mania  or  coma,  spasm  or  paralysis,  hyperesthesia 
or  anesthesia,  if  the  intellectual,  motor,  or  sensory  centers  respectively 
are  involved. 


Pig.  257. — (Walsham.)  The  cortical  areas  of  the  convexity  of  the  left  cere- 
brum. Fi,  P2,  F3.  Frontal  convolutions.  F3.  Center  for  speech.  Ti,  T2,  T3. 
Temporosphenoidal  convolutions.  Ti,  center  for  hearing.  A.  Angular  convolution, 
the  area  of  clear  vision  connected  with  the  yellow  spot.  F.  S.  Sylvian  fissure.  O. 
Occipital  lobe.  P  P.  Intraparietal  fissure.  POP.  Parietooccipital  fissure.  Recent 
observations  tend  to  show  that  in  man  the  sensorimotor  areas  do  not  extend  much 
behind  the  fissure  of  Rolando,  but  lie  mainly  in  front  of  it.      (Sherrington.) 


Pig.  258. — (Walsham.)  Median  surface  of  left  cerebrum.  G  P.  Gyrus  fornicatus; 
perhaps  connected  with  general  sensation,  its  impairment  causes  hemianesthesia.  C. 
Cuneus.  C  M  P.  Callosomarginal  fissure.  E.  Quadrate  lobule.  G  P.  Calcarine  fissure. 
U.  Uncinate  lobule. 


The  motor  area  (Figs.  257,  258)  occupies  the  ascending  frontal 
convolution  (which  lies  just  in  front  of  the  fissure  of  Rolando)  and 
extends  to  the  mesial  surface  of  the  brain.  On  the  cortex  the  leg 
center  occupies  the  upper  third,  the  arm  center  the  middle  third, 
the  face  center  the  lower  third;  on  the  median  surface  from  before 


5o6  MANUAL    OF    SURGERY      ' 

backward  are  the  centers  for  the  head,  trunk,  and  leg.     The  motor 
area  presides  over  the  muscles  of  the  opposite  side  of  the  body.     A 
lesion  in  a  motor  center  causes  localized  convulsions  followed  by 
paralysis  (monoplegia) ;  paralysis  without  preceding  spasm  occurs 
in  subcortical  lesions.     Lesions  of  the  internal  capsule  cause  hemiple- 
gia without  convulsions;  of  the  pons,  paralysis  of  the  face  on  the 
same  side  and  of  the  limbs  on  the  opposite  side  (crossed  paralysis) . 
Spastic  paralysis  indicates  a  lesion  of  the  conducting  tract  rather 
than  the  motor  centers.     The  centers  for  general  sensation,  arranged 
in  like  order,  lie  in  the  post-central  or  ascending  parietal  convolution, 
just  behind  the  fissure  of  Rolando.     The  center  for  vision  is  in  the 
cuneus,  which  lies  in  the  occipital  lobe  between  the  parieto-occipital 
and  calcarine  fissures  (Fig.  258);  unilateral  destruction  of  this  area 
results  in  hemianopsia,  or  blindness  of  the  corresponding  half  of 
each  retina.     The  auditory  center  is  in  the  middle  and  posterior 
parts   of   the  first  temporosphenoidal  gyrus,  while  smell  and  taste 
are  located  in  the  uncus,  which  is  the  anterior  extremity  of  the  hip- 
pocampal  convolution;  these  centers  are  bilateral,  hence  both  sides 
must  be  damaged  to  cause  total  abolition  of  hearing,  smell,  or  taste. 
The  center  for  speech  is  the  posterior  half  of  the  third  left  frontal 
convolution  (Broca's  convolution) ,  in  right  handed  people;  in  the  left 
handed  it  is  on  the  right  side.     Destruction  of  this  center  causes 
motor  aphasia,  or  loss  of  speech.     It  is  usually  associated  with  agra- 
phia, or  inabihty  to  write,  which  points  to  a  lesion  near  the  hand 
center  or  a  lesion  of  the  second  frontal  convolution.     Sensory  or 
amnesic  aphasia  includes  many  compHcated  symptoms,  the  most 
important  of  which  are  word  deafness,  indicating  a  lesion  in  the  post- 
erior half  of  the  first  or  second  temporal  convolution,  and  word 
blindness  {alexia),  in  which  the  angular  and  supramarginal  gyri  are 
at  fault.     Apraxia,  or  loss  of  memory  of  the  use,  color,  odor,  taste, 
etc.,  of  objects,  also  points  to  a  lesion  in  the  supramarginal  and 
angular  gyri.     The  stereo  gnostic  center  is  in  the  superior  parietal 
lobule ;  a  lesion  in  this  region  causes  aster eo gnosis,  or  loss  of  power  to 
recognize  the  size  and  shape  of  objects.     Reason,  intelligence,  and  will 
are  supposed  to  reside  in  the  superior  and  middle  frontal  convolu- 
tions, particularly  those  of  the  left  side.     Affections  of  the  cerebellum, 
especially  of  the  middle  lobe,  cause  vertigo  and  ataxia;  lesions  of  the 
lateral  lobe  cause  the  patient  to  fall  toward  the  affected  side.     Those 
portions  of  the  brain  in  which  lesions  do  not  cause  locaHzing  symp- 
toms are  called  silent  or  latent  regions,  viz.,  the  anterior  portion  of 
the  frontal  lobes,  the  temporosphenoidal  lobes  except  in  part  on 
the  left  side,  a  large  part  of  the  parietal  and  occipital  lobes,  and  a 
portion  of  the  cerebellum. 


HEAD  507 

The  lechnic  of  cerebral  surgery  includes  the  instructions  laid  down 
under  general  technic  (q.v.) .     A  special  assistant  should  be  assigned 
to  make  blood-pressure  records  at  frequent  intervals;  if  the  blood  pres- 
sure falls  below  100  the  operation  should,  if  possible,  be  interrupted, 
and  completed  at  a  later  period.     The  head  is  shaved  and  carefully- 
examined  for  scars,  etc.     It  is  disinfected  with  soap  and  water, 
alcohol,  and  bichlorid  of  mercury,  i  to  4,000,  the  day  before  opera- 
tion, and  again  at  the  time  of  operation.     In  emergency  cases  disin- 
fection can  be  carried  out  only  immediately  before  operation.     Ether 
increases  the  bleeding,  but  is  safer  than  chloroform  for  ansthesia. 
Local  anesthesia  is  preferred  by  many  to  avoid  the  increased  intra- 
cranial tension  and  profuse  bleeding  from  the  scalp  which  results  with 
general  narcosis.     The  fissures  may  be  marked  out  with  an  anihne 
pencil  or  with  iodin,  but  as  it  will  be  necessary  to  reflect  the  soft 
parts,  the  center-pin  of  a  trephine  should  be  forced  through  the 
scalp,  in  order  to  mark  the  bone,  in  three  places,  viz.,  at  each  end  of 
the  fissure  of  Rolando,  and  at  the  point  which  will  occupy  the  center 
of  the  trephine  opening.     The  head  should  be  raised  on  a  sand  pillow 
in  order  to  give  it  firm  support  and  lessen  bleeding.     Unless  the 
operation   can  be  performed  by  enlarging  an   existing  wound,   a 
horseshoe-shaped  flap,  with  the  base    downward  to   preserve  the 
blood  supply  and  including  the  periosteum,  is  reflected  from  the 
skull.     The  skull  may  be  opened  with  a  trephine,    gouge,    chisel 
Gigli's  wire  saw,  or  with  a  special  drill  and  saw  attached  to  a  dental 
engine  or  electric  motor,  and  any  of  these  openings  may  be  enlarged 
with  rongeur  forceps,  after  separating  the  dura  from  the  skull  with  a 
Horsley's  dural  separator,  with  which  the  inner  surface  of  the  skull 
may  also  be  explored.     The  trephine  (Fig.  259)  is  a  hollow  cylinder 
with  a  saw-edge.     It  is  provided  with  a  center-pin,  which  projects 
beyond  the  saw-edge,  and  holds  the  instrument  in  place  until  a 
groove  in  the  skull  has  been  made.     The  pin  is  then  withdrawn,  and 
the  section  completed  by  twisting  the  trephine  from  left  to  right 
and  from  right  to  left.     When  the  diploe  has  been  reached,  there 
wiU  be  more  bleeding  and  lessened  resistance.     The  inner  table  is 
recognized  by  its  density;  at  this  time  one  should  proceed  with 
caution  and  frequently  test  the  depth  of  the  groove  with  the  flat  end 
of  a  probe.     If  one  segment  of  the  circle  is  cut  through  before  the 
remainder,  the  trephine  is  tilted  so  as  to  avoid  injury  to  the  dura. 
The  trephine  should  be  conical,  or  provided  with  guards,  so  that  it 
it  cannot  plunge  suddenly  into  the  brain.     A  trephine  three-fourths 
of  an  inch  in  diameter  is  the  best  size  for  most  purposes.     Very 


5o8  MANUAL    OF   SURGERY 

large  trephines  are  difficult  to  manage,  owing  to  the  amount  of  bone 
to  be  cut  and  the  curvature  of  the  skull.  By  osteoplastic  resection 
is  meant  the  turning  back  of  a  trap-door,  consisting  of  scalp  and 
bone,  which  is  replaced  at  the  completion  of  the  operation.  The 
flap  is  outhned  by  an  incision  extending  down  to  the  bone,  but  the 
scalp  is  not  separated  from  the  skull.  A  groove  is  then  made  in  the 
bone,  in  the  line  of  incision,  with  chisel  or  saw,  and  the  section  com- 


FiG.   259. — (i)  Gigli  wire  saw;  (2)  Horsley's  dural  separator;  (3)  rongeur  forceps;  (4) 
trephine;  (5),  Keen's  rongeur  forceps. 

pleted  with  an  osteotome.  Elevators  are  placed  beneath  the  flap 
which  is  pried  upwards,  and  turned  back  by  fracturing  the  bone  at  its 
base.  By  making  a  small  opening  on  each  side  of  the  base  and  at 
each  corner  of  a  ^-shaped  flap,  with  a  trephine,  or,  better,  with  a 
Hudson  burr  (Figs.  260,  261,  and  262),  the  intervening  bone  may  be 
severed  with  forceps  (Fig.  263),  or  with  the  Gigli  wire  saw,  which 
is  passed  from  one  opening  to  the  other  beneath  the  bone  and  over  a 


HEAD 


509 


grooved  director,  the  bone  being  divided  from  within  outwards, on  a 
bevel,  thus  preventing  the  bone  from  pressing  on  the  brain  when  it  is 
replaced.  Stellwagon  has  invented  an  ingenious  instrument  for 
quickly  making  a  trap-door  in  the  skull.     Osteoplastic  resection  is 


Pig.  260.  Fig.  261.  Pig.  262. 

Figs.  260  to  262. — Hudson's  burrs.  These  burrs  are  driven  by  a  hand-brace,  and 
cut  rapidly  through  the  skull,  but  bind  as  soon  as  they  reach  the  dura,  thus  preserving 
that  membrane  from  injury.  The  smallest  burr  is  used  first,  then  the  opening  widened 
with  the  larger  burrs. 


used  chiefly  for  exploratory  purposes  or  for  the  removal  of  tumors, 
in  other  words,  when  it  is  desirable  to  expose  a  large  extent  of  the 
cortex. 

The  dura  is  opened  about  one-fourth  inch  away  from  the  bone 
so  that  subsequent  suturing  will  be  facilitated.     It  is  lifted  from  the 


Pig.   263. — Hudson's  modification  of  the  De  Vilbiss  forceps. 

brain  with  rat-tooth  forceps,  nicked  with  a  knife,  and  the  flap  com- 
pleted with  scissors.  No  antiseptic  should  be  used  after  the  dura  is 
opened.  Irrigation  with  salt  solution  also  is  contraindicated.  It 
should  be  noted  whether  the  membranes  are  edematous,  and  whether 
the  brain  pulsates  or  bulges.     Bulging  and  absence  of  pulsation 


5IO  M.A.NUAL   OF    SURGERY 

indicate  a  marked  increase  in  intracranial  pressure  (tumor,  abscess, 
■cyst,  etc.).  Lividity,  a  yellowish  color,  or  an  increase  in  density  as 
determined  by  the  finger,  point  to  a  tumor.  The  exposed  centers 
may  be  stimulated  with  Keen's  double  brain-electrode  in  order  to 
corroborate  the  findings  of  craniocerebral  topography.  The  current 
should  be  no  more  powerful  than  that  required  to  move  the  muscles 
of  the  thumb.  If  further  exploration  is  desirable,  the  brain  may  be 
punctured  with  a  needle  or  grooved  director,  or  even  incised.  In 
removing  diseased  brain  tissue  anteroposterior  incisions  do  less 
harm  to  the  centers  than  those  placed  in  a  vertical  direction. 

Hemorrhage  from  the  scalp  is  controlled  temporarily  with  hemos- 
tatic forceps,  or  tourniquet  clamps,  permanently  with  ligatures  or 
sutures.  Bleeding  from  the  bone  is  checked  by  gauze  pressure,  by 
crushing  pieces  of  muscle  into  the  edge  of  the  bone  with  forceps,  or 
best  by  Horsely's  wax  (beeswax  7,  almond  oil  i,  saHcyKc  acid  i). 
Blood  vessels  in  the  dura  and  brain  may  be  tied  with  fine  suture- 
ligatures  of  silk  or  catgut,  general  oozing  may  be  controlled  with 
hot  compresses  or  by  applying  small  sections  of  tissue  removed  from 
the  temporal  muscle  (Gushing).  Bleeding  from  a  sinus  may  readily 
be  controlled  by  gauze  packing,  which  should  be  left  in  place  several 
days;  other  procedures  for  the  same  purpose  are  to  catch  the  wound 
with  forceps,  which  remain  for  several  days,  to  apply  a  lateral  liga- 
ture, to  suture  the  opening,  and  to  ligate  the  entire  sinus. 

The  dura  should  be  sutured  with  catgut,  the  scalp  with  silkworm 
gut,  and  a  copious  dressing  applied.  The  head  should  be  slightly 
elevated,  and  the  patient  kept  absolutely  quite. 

Excepting  osteoplastic  resection,  the  bone  is  ordinarily  not  re- 
placed, the  defect  in  the  skull  being  remedied  in  time  by  dense 
fibrous  tissue.  Bone,  either  in  chips  or  in  the  form  of  a  button,  may 
however,  be  replaced,  if  during  the  operation  it  is  kept  in  salt  solu- 
tion at  a  temperature  of  105  degrees.  Osseous  defects  in  the  skull 
are  closed  by  grafts  of  cartilage  from  near  the  sterum,  by  fascia 
lata  as  well  as  with  a  portion  of  the  outer  table  of  the  neighboring 
skull,  transferred  to  the  opening  by  means  of  a  flap  of  scalp.  In 
children,  in  whom,  owdng  to  the  thin  cranium  and  scalp,  the  last 
mentioned  proceeding  is  difficult,  the  defect  may  be  filled  with  a 
transplant  of  periosteum  and  bone  from  the  inner  surface  of  the 
tibia,  or  a  piece  of  the  body  of  the  scapala,  which  possesses  the  advan- 
tage of  having  periosteum  on  both  sides.  Suggestions  for  the  closure 
of  defects  in  the  dura  will  be  found  under  hernia  cerebri.  Attempts 
have  been  made  to  prevent  adhesions  between  the  brain  and  over- 


HEAD  511 

lying  structures  by  interposing  rubber  tissue,  egg  membrane,  collodion, 
gold  and  silver  foil,  etc.,  and  by  the  free  transplantation  of  fat. 

INJURIES  TO  THE  CRANIUM  AND  ITS  CONTENTS 

Concussion  of  the  brain  is  due  to  a  shaking  or  jarring  of  the  brain 
by  direct  (e.g.,  a  blow  on  the  head)  or  indirect  force  (e.g.,  a  fall  on  the 
buttocks).  In  the  mildest  form  no  anatomical  changes  take  place, 
but  in  the  severe  variety  there  are  lacerations  of  the  brain  tissue  and 
blood  vessels.  If  the  bleeding  from  these  lacerations  is  sufficiently 
great  to  exert  pressure  on  the  brain,  or  if  edema  supervenes,  the 
condition  is  one  of  compression  rather  than  concussion. 

The  S5miptoms  vary  from  temporary  giddiness  or  stunning,  to 
collapse  and  death.  In  a  well  marked  case  there  is  unconsciousness 
which  is  rarely  complete,  in  that  the  patient  may  be  partly  roused  by 
shouting,  pricking  the  soles  of  the  feet,  etc.  The  muscles  are  relaxed, 
the  skin  cold  and  pale,  the  temperature  subnormal,  the  respirations 
slow  and  shallow,  the  pulse  weak  and  rapid.  The  pupils  are  equal, 
react  to  light,  and  are  usually  dilated.  The  reflexes  are  sluggish  or, 
in  the  severest  cases,  abolished.  The  sphincters  are  relaxed,  so 
that  involuntary  evacuations  from  the  bowel  may  occur,  but  reten- 
tion of  urine  is  more  common  than  its  expulsion  owing  to  relaxation 
of  the  bladder  muscle.  Transient  paralyses  may  exist.  This  is  the 
stage  of  collapse,  which  may  last  from  minutes  to  hours;  it  ends 
either  in  death  or  in  the  stage  of  reaction,  which  may  be  inagurated 
by  a  convulsion,  or  more  commonly  by  slight  movements  of  the 
extremities  and  vomiting.  The  symptoms  mentioned  above  grad- 
ually disappear,  the  temperature  rises,  perhaps  to  ioo°F.  or  a  Uttle 
above,  and  there  is  headache,  drowsiness,  or  irritability,  which  may 
last  a  number  of  days. 

The  prognosis  should  always  be  guarded,  although  in  most  cases 
complete  and  permanent  recovery  follows.  The  early  dangers  are 
compression  from  hemorrhage  or  edema,  and  inflammation  of  the 
brain  or  meninges.  Among  the  sequelae  may  be  mentioned  cerebral 
irriabihty,  inveterate  headache,  vertigo,  loss  of  memory,  change  in 
character,  insanity,  epilepsy,  diabetes,  neurasthenia  and  possibly 
tumor  or  abscess.  Frequently  the  patient's  memory  is  defective  for 
the  events  immediately  preceding  the  accident. 

The  treatment  during  the  stage  of  collapse  is  the  application  of 
external  heat  and  the  administration  of  stimulants  as  in  shock. 
Alcohol,  however,  should  not  be  given  because  of  its  exciting  effect 
on  the  brain,  and  care  should  be  taken  not  to  overstimulate.     When 


512  MANUAL    OF    SURGERY 

reaction  has  been  obtained,  the  patient  should  be  kept  in  bed  in  a 
quite  room,  an  ice  bag  placed  on  the  head,  the  bowels  opened  with 
a  purge,  and  the  catheter  used  if  there  is  retention  of  urine.  The 
diet  should  be  fluid  and  sedatives  used  if  necessary.  If  unconscious- 
ness is  prolonged  a  suspicion  of  greater  injury  than  concussion  should 
always  be  entertained.  After  severe  concussion  the  patient  should 
avoid  mental  exertion  for  a  number  of  weeks  or  months. 

Cerebral  irritability  may  come  on  in  a  few  hours  or  days  after 
severe  concussion  of  the  brain.  The  patient  lies  curled  up  on  his 
side,  is  restless,  irritable,  or  delirious,  and  perhaps  has  involuntary 
evacuations  from  the  bladder  and  bowels;  the  eyes  are  closed,  the 
pupils  contracted  but  react  to  light,  the  temperature  slightly  elevated 
the  pulse  weak  and  slow.  The  condition  lasts  a  few  days  or  several 
weeks,  and  ends  in  complete  recovery  or  in  permanent  impairment 
of  the  mental  faculties.  The  treatment  is  the  same  as  that  for  the 
second  stage  of  concussion. 

Compression  of  the  brain  may  be  caused  by  depressed  fracture, 
foreign  body,  intracranial  hemorrhage,  hydrocephalus,  inflammatory 
products  (including  abscess  and  edema),  and  by  cysts  and  tumors 
(including  gumma  and  tuberculous  deposits).  It  may  be  localized 
to  a  single  center,  group  of  centers,  e.g.,  in  depressed  fracture,  or 
generalized,  e.g.,  in  hydrocephalus;  or  e.g.,  in  intracranial  hemorrhage 
it  may  begin  as  the  former  and,  as  the  pressure  increases,  gradually 
merge  into  the  latter. 

The  pathological  changes  are,  first,  a  displacement  of  the  cerebro- 
spinal fluid,  then  compression  of  the  blood-vessels,  the  veins  col- 
lapsing primarily,  owing  to  their  thin  walls  and  the  low  intravenous 
blood  pressure,  and  finally  capillary  anemia,  with  loss  of  function  in 
the  anemic  parts.  As  the  cranial  cavity  is  divided  into  three  com- 
partments by  the  falx  and  the  tentorium,  pressure  in  one  of  these 
compartments  may  become  very  great  before  causing  generalized 
compression.  When  subtentorial  pressure  is  increased  and  the  blood 
supply  to  the  medulla  decreased,  the  vasomotor  center  at  once 
becomes  more  active  and  the  blood  pressure  rises ;  thus  there  may  be 
oscillations  in  the  blood  pressure  and  consequently  irregularity  of  the 
medullary  circulation,  with  irregular  action  of  the  respiratory  center 
(Cheyne-Stokes  respiration)  and  intermittent  pulse.  Finally  intra- 
cranial pressure  exceeds  the  limit  which  intravascular  pressure  may 
attain  and  death  ensues. 

The  S3miptoms  are  immediate  in  depressed  fracture,  foreign 
bodies,  and  apoplexy.  The  onset  is  delayed  in  middle  meningeal 
hemorrhage  and  in  inflammatory  exudates,  and  is  very  gradual  in 


HEAD  513 

tumors,  cysts,  and  chronic  hydrocephalus.  In  traumatic  cases  the 
symptoms  may  be  preceeded  ])y  or  mixed  with  those  of  concussion. 
Local  compression  causes  irritation  or  paralysis  of  the  center  affected, 
according  to  the  degree  of  pressure.  The  symptoms  of  generalized 
compression,  and  this  is  usually  what  is  meant  when  one  speaks  of 
cerebral  com])ressi()n,  are,  when  the  condition  develops  gradually, 
(i)  those  of  irritation  and,  as  the  pressure  becomes  more  marked, 
those  of  paralysis  of  (2)  the  cortical  and  fmally  (3)  the  bulbar 
centers,  (t)  During  the  first  stage  there  may  be  headache,  vertigo, 
restlessness,  delirium,  convulsions,  vomiting,  tinnitus,  contracted 
pupils,  and  choked  disc.  The  pulse  is  slow  and  full,  the  blood 
pressure  elevated,  and  the  respirations  more  rapid  and  deeper,  from 
stimulation  of  the  vagus,  vasomotor,  and  respiratory  centers.  The 
temperature  varies  with  the  cause  of  compression,  thus  trauma, 
hemorrhage,  and  shock  lower  it,  while  inflammatory  conditions  and 
lesions  of  the  pons  and  medulla  elevate  it.  Lumbar  puncture  in 
this  and  the  succeeding  stages  may  reveal  increased  tension  of  the 
cerebrospinal  fluid,  which  may  contain  blood  (in  traumatic  cases), 
pus  (in  meningitis),  or  other  evidences  of  the  causative  lesion  (see 
spinal  puncture).  (2)  In  the  second  stage,  or  the  stage  of  fully 
developed  compression,  the  excitement  gives  place  to  stupor  and 
finally  to  complete  unconsciousness,  i.e.,  the  patient  cannot  be 
roused  by  shouting,  pricking  the  soles  of  the  feet,  etc.  The  face  is 
more  or  less  cyanotic  and  the  veins  of  the  eyelids  distended.  As  the 
medullary  centers  resist  longer  than  the  cortex  the  pulse  remains  full 
and  slow  and  the  blood  pressure  high.  The  respiratory  center  is  the 
first  of  the  medullary  centers  to  show  signs  of  weakening,  hence  the 
breathing  becomes  slow  and  stertorous.  The  stertor  is  due  to 
paralysis  of  the  soft  plate,  the  flapping  of  the  cheeks  to  paralysis  of 
the  fascial  muscles.  (3)  In  the  final  stage  the  respirations  are  rapid, 
irregular,  and  of  the  Cheyne-Stokes  variety;  the  pupils  are  dilated, 
perhaps  unequal,  and  do  not  respond  to  light;  and  there  are  reten- 
tion of  urine  from  paralysis  of  the  bladder,  and  involuntary  fecal 
evacuations  from  relaxation  of  the  sphincter  ani.  Localized  paraly- 
ses may  be  detected  on  one  side  of  the  body  in  the  early  stages,  but 
in  the  final  stage  all  the  muscles  are  equally  relaxed.  The  temper- 
ature usually  rises  and  in  fatal  cases  may  reach  106°  or  io8°F.  The 
blood  pressure  falls  (paralysis  of  the  vasomotor  center)  and  the  pulse 
becomes  rapid  and  often  intermittent  (paralysis  of  the  vagus  center), 
death  ultimately  occurring,  however,  from  respiratory  failure,  as  the 
heart  continues  to  beat  for  some  minutes  after  breathing  ceases. 

The  diagnosis  may  be  very  difficult  in  cases  in  which  no  history 
33 


514 


MANUAL    OF    SURGERY 


can  be  obtained.  Most  cases  of  unconsciousness  are  due  to  toxemia 
(e.g.,  from  nephritis,  diabetes,  infective  maladies,  terminal  infection 
in  noninfective  diseases,  ingested  poisons,  including  alcohol),  cardiac 
disease,  syncope,  apnea  (e.g.,  from  foreign  bodies  in  the  air  passages, 
coal  gas,  smoke,  drowning,  embolism  of  the  pulmonary  artery), 
disease  or  injury  of  the  brain  (e.g.,  cerebral  concussion,  compression, 
or  embolism;  epilepsy;  catalepsy;  hysteria),  shock  (some  of  the 
causes  of  which  may  be  overlooked,  e.g.,  internal  hemorrhage, 
hghtning  stroke,  shock  from  artificial  electric  currents),  sunstroke, 
freezing,  or  malingering.  The  surgeon's  chief  concern  in  these  cases 
is  to  determine  whether  the  condition  demands  operation  or  the 
services  of  his  medical  colleague.  If  the  patient  is  cyanosed  the 
first  condition  to  be  thought  of,  because  of  the  necessity  for  instan- 
taneous action,  is  apnea,  particularly  from  a  foreign  body  in  the 
air  passages,  and  especially  if  the  individual  has  suddenly  fallen 
unconscious  while  eating.  If  pallor  is  marked  and  there  is  no' 
external  wound  the  first  consideration  should  be  internal  hemorrhage. 
After  apnea  and  hemorrhage  one  should  think  first  of  poisoning, 
evidences  of  which  may  be  found  in  the  odor  of  the  breath,  on  the 
lips,  in  the  mouth  (e.g.,  from  corrosives),  or  in  the  gastric  contents; 
a  farewell  letter  or  an  empty  bottle  may  be  discovered  in  the  patient's 
pocket.  Aside  from  the  investigations  just  suggested,  and  in  addi- 
tion to  careful  scrutiny  of  the  scalp  for  injuries,  including  incision  of  a 
contusion  for  the  purpose  of  inspecting  the  skull,  many  mistakes  may 
be  avoided,  in  doubtful  cases,  by  examining  the  urine  and  the  eye 
grounds,  by  lumbar  puncture,  and  by  making  a  skiagram  of  the  head. 
The  forms  of  unconsciousness  most  frequently  confused  with  com- 
pression of  the  brain  are  mentioned  below. 

The  symptoms  of  concussion  should  be  compared  with  those  of 
compression.  Errors  are  most  likely  to  arise  in  the  first  stage  of 
compression,  and  in  cases  in  which  concussion  precedes  and  merges 
with  compression,  eg.,  intracranial  hemorrhage. 

In  acute  alcoholism  the  patient  is  not  absolutely  unconscious;  the 
pupils  are  dilated,  equal,  and  react  to  fight;  the  pulse  is  frequent; 
and  there  are  no  paralyses.  Dilated  varices  on  the  face,  injected 
eyes,  and  the  odor  of  alcohol,  are  of  lesser  importance,  since  an 
alcohoHc  may  have  a  fracture  of  the  skull,  and  an  injured  man  may 
have  been  given  whisky,  A  drunken  individual  improves  after 
washing  out  the  stomach  and  as  the  effects  of  the  alcohol  pass  away. 
In  doubtful  cases  any  contusion  of  the  scalp  should  be  investigated 
by  incision,  and  the  patient  watched  for  symptoms  of  compression. 

In  opium  poisoning  the  respirations  are  very  slow,  the  pupils 


HEAD  .  515 

small,  and  paralyses  absent.  It  should  be  recalled  that  in  pontine 
hemorrhage  the  pupils  are  contracted,  but  there  are  crossed  paralysis 
and  a  high  temperature. 

In  uremia  the  coma  follows  convulsions,  the  temperature  is 
subnormal,  the  face  and  feet  are  edematous,  the  pupils  are  normal  or 
dilated,  albuminuric  retinitis  is  sometimes  present,  albumin  and  casts 
are  found  in  the  urine,  and  paralyses,  except  in  rare  cases,  are  absent. 
A  chronic  nephritis  is,  because  of  the  associated  arteriosclerosis, 
predisposed  to  apoplexy,  and  uremic  coma  may  be  accompanied  by 
compression  of  the  brain  due  to  edema. 

In  apoplexy  all  the  symptoms  of  compression  are  present,  and  the 
diagnosis  can  be  made  only  by  the  history  and  the  absence  of  local 
evidences  of  injury.  The  X-ray  may  be  of  service  in  excluding  frac- 
ture of  the  skull,  lumbar  puncture  in  excluding  subdural  hemorrhage. 

Diabetic  coma  follows  somnolence,  the  respirations  are  rapid,  the 
pulse  weak,  and  there  are  sugar  and  perhaps  acetone  and  diacetic 
acid  in  the  urine,  a  sweet  odor  to  the  breath,  and  no  paralyses. 

The  treatment  of  cerebral  compression,  which  is  removal  of  the 
compressing  agent  whenever  possible,  is  given  in  more  detail  in  dis- 
cussing the  causative  conditions  mentioned  above.  Irrespective  of 
the  cause,  however,  it  may  be  advisable  to  trephine  simply  for  the 
relief  of  pressure. 

Fractures  of  the  skull  are  divided  into  those  of  the  vault  and  those 
of  the  base.  They  are  produced  in  four  ways,  (i)  Bending,  or 
impression  fractures  (confined  always  exclusively  to  the  vault), 
are  due  to  violence  restricted  to  a  small  area  of  the  skull,  e.g.,  a  blow 
from  a  hammer  the  bone  bending  inward  until  it  breaks.  As  with  a 
stick  that  is  broken  by  bending,  the  fracture  begins  and  is  more 
extensive  on  the  surface  made  convex  by  the  bending,  i.e.,  the  inner 
table.  .  (2)  Bursting,  or  compression  fractures,  may  involve  the  vault, 
the  base,  or  both.  As  the  skull  is  elastic,  when  the  head  is  squeezed 
between  two  objects  the  axis  between  the  poles  of  compression  is 
shortened,  the  equator  lengthened,  and  the  meridians  of  longitude 
separated,  the  greatest  gap  occurring  at  the  equator  hence,  the  line 
of  fracture  runs  parallel  with  the  direction  of  the  compressing  force. 
The  same  changes  may  occur  when  the  head  strikes  a  broad,  hard 
object,  as  in  a  fall  on  the  pavement,  or  when  a  broad,  hard  object 
strikes  the  head.  Since  the  skull  is  not  spherical  and  varies  greatly 
in  thickness  and  structure  in  its  different  parts,  the  fracture  does  not 
occur  at  the  mathematical  equator,  but  at  the  most  inelastic  point  in 
the  expanding  portion  of  the  skull.  When  this  point  is  on  the 
opposite  side  to  that  which  has  been  struck,  the  fracture  is  some- 


5l6  MANUAL    OF    SURGERY 

times,  although  incorrectly,  called  ''hacture  by  coiitrc  coup.''  Frac- 
ture by  contre  coup  does  not  exist.  (3)  Splitting  or  wedge  action, 
is  exemphfied  when  an  instrument  like  a  chisel  is  driven  into  the 
skull,  the  bone  splitting  like  a  piece  of  wood.  (4)  Explosive  action 
occurs  in  some  gunshot  wounds,  weaves  of  force  being  transmitted 
from  the  bullet  to  the  cranial  contents,  the  skull  sufi"ering  extensive 
comminution. 

In  the  repair  of  fractures  of  the  skull  very  little  callus  is  thro.wn 
out,  possibly  because  of  the  perfect  immobilization.  Completely 
detached  fragments  may,  in  the  absence  of  sepsis,  survive  and  unite 
with  each  other  and  with  the  uninjured  bone.  Defects  in  the  cranium 
following  injury  or  operation  are  ultimately  filled  in  with  firm 
fibrous  tissue,  which,  if  the  opening  is  small,  may  undergo  complete 
ossification,  the  new  bone  forming  from  the  dura  and  from  the 
pericranium  at  the  margins  of  the  openings.  Large  gaps,  however, 
are  seldom  entirely  closed  by  bone.  Suggestions  for  the  operative 
closure  of  such  openings  are  made  in  the  section  on  the  technic  of 
cerebral  surgery. 

Fractures  of  the  vault  are  caused  by  direct  or  indirect  violence; 
in  the  latter  instance  the  bone  yields  from  compression  of  the  skull. 
Like  fractures  elsewhere  those  of  the  skull  may  be  simple  or  compound, 
complete  or  partial.  The  best  example  of  incomplete  fracture  is 
that  of  the  outer  table  in  the  region  of  the  frontal  sinus,  the  inner 
table  being  uninjured.  Fracture  of  the  inner  table  alone  is  rare. 
In  children  the  skull  may  be  indented  without  fracture  of  either 
table.  The  usual  injury  is  a  fissured  fracture;  if  several  fissures 
radiate  from  one  point  the  injury  is  called  a  stellate  fracture.  De- 
pressed fractures  are  generally  comminuted.  The  depression  may 
slope  evenly  from  the  sound  bone  {saucer  or  pond-shaped  fracture), 
or  the  fragment  or  fragments  may  be  completely  detached. and  de- 
pressed below  the  inner  table  {gutter  fracture).  Punctured  fractures 
are,  as  a  rule,  comminuted  and  depressed,  but  the  area  involved  is 
small.  In  all  complete  fractures  the  inner  table  is  usually  more 
involved  than  the  outer,  owing  to  its  lack  of  support  and  greater 
brittleness.  and  owing  to  the  diffusion  of  the  force,  as  pointed  out 
above. 

Symptoms  in  a  simple  fissure-fracture,  apart  from  local  bruising, 
may  be  absent,  and  the  condition  can  be  recognized  with  certainty 
only  by  the  X-ray.  or  after  exploratory  incision,  which  should  be 
done  if  there  are  evidences  of  compression  or  severe  concussion. 
Occasionally  a  cracked-pot  sound  is  obtained,  and  in  rare  instances 
a  spurious  meningocele  forms.     In  simple  depressed  fracture  the 


HEAD  5 I 7 

indentation  may  he  masked  by  swelling.  An  old  scar  or  a  hematoma 
may  feel  like  a  depression  (see  hematoma  of  the  scalj)).  In  compound 
cases  the  fracture  may  be  seen  and  felt,  and  if  the  dura  is  injured 
there  will  be  an  escape  of  cerebrospinal  fluid  and  possibly  of  brain 
tissue.  The  possibility  of  mistaking  a  suture,  a  slit  in  the  peri- 
cranium, or  a  tear  in  the  temporal  fascia  for  a  fracture  should  be 
recalled  (see  wounds  of  the  scalp).  Fracture  of  the  inner  table  alone 
is  diagnosticated  only  by  the  X-ray  or  after  trephining  for  the  associ- 
ated brain  symptoms.  The  general  cerebral  symptoms  may  be 
of  concussion  or  compression.  The  localizing  cerebral  signs  depend 
on  the  region  involved  (p.  503).  In  any  fracture  accompanied 
by  subdural  hemorrhage  lumbar  puncture  shows  bloody  cere- 
brospinal fluid.  The  prognosis  is  that  of  the  complicating  injury  of 
the  brain.  The  immediate  dangers  are  shock,  laceration  of  the 
brain,  and  compression  from  bone  or  blood.  The  intermediate 
danger  is  septic  inflammation;  and  the  remote  dangers  those  of 
concussion  (q.v.).  Of  all  cases  of  fractured  skull  that  recover  about 
one-half  develop,  in  some  degree,  remote  ill  effects,  and  probably  20 
per  cent,  of  these  are  seriously  affected. 

Treatment  is  required  for  (i)  disinfection,  (2)  depression,  or 
(3)  compression,  i.  All  compound  fractures  must  be  disinfected; 
when  the  injury  is  even  a  fissure,  it  will  often  be  necessary  to  remove 
the  line  of  fracture  by  gouge  or  rongeur,  owing  to  the  presence  of 
hair  or  dirt  which  has  been  driven  into  the  crack.  2.  If  depression 
exists,  whether  the  fracture  is  simple  or  compound  and  whether  there 
are  symptoms  of  intracranial  trouble  or  not,  the  bone  should  be 
pried  into  place  by  an  elevator.  If  an  opening  sufficiently  large  for 
the  elevator  does  not  exist,  it  will  be  necessary  to  trephine,  the  center- 
pin  being  placed  upon  the  sound  bone  near  the  fracture.  If  there 
is  much  comminution,  it  may  be  better  to  remove  the  fragments.  In 
simple  depressed  fractures  in  children  the  same  rule  should  apply  as 
in  adults,  although  some  authors  advise  expectant  treatment  in 
these  cases.  The  reason  for  trephining  in  depression  without  symp- 
toms is  to  prevent  subsequent  cerebral  troubles,  e.g.,  epilepsy, 
insanity.  Punctured  fractures  require  trephining  both  for  depres- 
sion and  disinfection.  3.  All  fractures,  whether  simple  or  compound, 
with  symptoms  of  compression  require  trephining.  The  only  cases 
which  are  treated  expectantly  are  those  of  simple  fracture  without 
depression  or  symptoms,  and  those  in  which  the  injury  is  very  exten- 
sive. 

Fractures  of  the  base  of  the  skull  are  caused  by  direct  violence,  a 
stabs  or  gunshot  wounds  through  the  orbit,  nose,  mouth,  ear,  or 


5l8  MAXUAL    OF    SURGERY 

occiput,  in  which  case  the  fracture  may  be  depressed;  a  similar 
injury  results  from  a  blow  on  the  chin  which  drives  the  condyles  of 
the  jaw  into  the  middle  fossa,  or  from  a  fall  on  the  head,  feet,  or 
buttocks,  which  drives  the  vertebral  column  upwards  into  the 
posterior  fossa.  Direct  fractures  are  caused  also  by  blows  at  the 
level  of  the  base  of  the  skull,  which  spHt  the  base  as  a  chisel  does  a 
piece  of  wood.  Indirect  fractures  are  caused  by  extension  of  a 
fracture  of  the  vault  (irradiation),  or  by  a  squeeze  of  the  head,  the 
resulting  fracture  running  parallel  with  the  direction  of  the  compress- 
ing force  (bursting  fracture),  moditied.  however,  by  the  Hnes  of  least 
resistance  in  the  base  of  the  skull.  Most  fractures  of  the  base  are 
compound,  communicating  with  the  air  through  the  orbit,  nose 
pharynx,  or  ear.  Fracture  of  the  middle  fossa  is  the  most  frequent; 
fracture  of  the  posterior  the  most  fatal,  because  of  the  vital  centers 
therein  contained.  The  dangers,  both  immediate  and  remote,  are 
those  of  fracture  of  the  vault,  except  that  here  the  important  struc- 
tures at  the  base  and  the  cranial  nerves  are  much  more  Ukely  to  be 
implicated. 

The  symptoms  are  usually  those  of  severe  concussion  or  compres- 
sion, although  both  may  be  absent.  The  temperature  is  at  first 
subnormal  from  shock,  then  rises  to  ioo°  or  ioi°F..  and  subse- 
quently falls  to  normal  or  subnormal.  A  continuous  rise  indicates 
extensive  injury  to  the  brain  or  meninges.  Fractures  invoking  the 
anterior  fossa  may  cause  prolonged  epistaxis  followed  by  a  flow  of 
cerebrospinal  fluid  from  the  nose,  and  subconjunctival  hemorrhage, 
which  is  recognized  by  its  occurrence  after  several  hours  or  days  and 
by  the  fact  that  it  comes  from  behind  forwards,  i.e.,  no  white  sclerotic 
can  be  seen  posterior  to  it.  If  the  bleeding  is  profuse  the  eye  may  be 
pushed  forward.  Escape  of  brain  tissue  from  the  nose  or  orbit  is 
rare.  The  first,  second,  or  third  cranial  nerves  may  be  injured.  In 
fractures  of  the  middle  fossa  blood  and  cerebrospinal  fluid,  rarely 
brain  tissue,  may  escape  from  the  ears  and  occasionally  from  the  nose 
or  mouth.  It  should  be  recalled  that  bleeding  from  the  ear  may 
be  caused  by  injury  to  the  bone  or  cartilage,  or  by  rupture 
of  the  tympanum  without  fracture  of  the  base,  and  that  a 
serous  fluid  may  come  from  the  mastoid  cells  and  inner  ear.  Cere- 
brospinal fluid  may  be  recognized  by  its  watery  character,  by  the 
increase  in  flow  on  straining  or  coughing,  and  by  chemical  examina- 
tion (see  spinal  puncture).  Ecchymosis  may  be  seen  in  the  tempo- 
roparietal region.  The  cranial  nerves  most  likely  to  be  injured  are 
the  sixth,  seventh,  and  eighth.  In  the  posterior  fossa  the  blood 
infiltrates  the  muscles  at  the  back  of  the  neck,  but  is  prevented  from 


HEAD  519 

reaching  the  skin  by  the  cervical  fascia,  except  along  the  course  of  the 
posterior  auricular  artery,  thus  causing  a  crescentic  line  of  ecchy- 
mosis  behind  the  ear  (Battle's  sign).  Escape  of  blood  from  the 
mouth  and  injury  to  the  cranial  nerves  are  rare.  Optic  neuritis 
occasionally  occurs  a  week  or  more  after  fracture  of  the  posterior 
fossa.  Bloody  cerebrospinal  fluid  may  be  obtained  by  lumbar  punc- 
ture, even  three  or  four  weeks  after  the  injury:  The  X-ray  often 
reveals  the  fracture. 

The  treatment  is  first  that  of  shock  as  indicated  under  concussion 
of  the  brain.  The  patient  should  be  put  in  a  dark  and  quiet  room, 
the  nose,  pharynx,  or  ear  disinfected  (Chap.  IV),  according  to  the 
situation  of  the  fracture,  and  in  case  of  the  ear  the  canal  plugged 
with  sterile  cotton  and  a  bandage  applied  over  an  external  dressing. 
Ice  should  be  appHed  to  the  head,  a  purgative  administered,  and  the 
patient  kept  on  a  fluid  diet.  In  a  punctured  wound  of  the  orbit 
involving  the  base  of  the  skull,  it  will  be  necessary  to  enlarge  the 
wound  in  order  to  disinfect  thoroughly;  in  some  of  these  cases  it 
may  be  advisable  to  trephine  above  the  orbit  to  remove  depressed 
fragments  and  disinfect.  Symptoms  of  compression  indicate  bilat- 
eral subtemporal  decompression  (Gushing),  i.e..  removal  of  a  portion 
of  bone  under  each  temporal  muscle,  with  incision  of  the  dura. 
The  mortality  is  in  the  neighborhood  of  75  per  cent. 

Intracranial  hemorrhage  maybe  spontaneous  (e.g., apoplexy)  or 
traumatic.  Spontaneous  hemorrhage  belongs  to  the  physician 
rather  than  to  the  surgeon,  although  in  certain  cases  of  ingravescent 
apoplexy  the  common  carotid  artery  has  been  tied,  and  in  ordinary 
apoplexy  the  removal  of  a  section  of  the  skull  has  been  suggested  in 
order  to  relieve  compression.  Traumatic  hemorrhage  may  be  ex- 
tradural (between  the  dura  and  the  bone),  subdural  (between  the 
dura  and  the  brain) ,  or  cerebral  (within  the  brain) . 

Extradural  hemorrhage  may  be  due  to  a  wounded  sinus,  but  is 
most  commonly  caused  by  rupture  of  the  middle  meningeal  artery 
or  one  of  its  branches.  Fracture  is  usually  but  not  invariably  present. 
Rarely  the  bleeding  is  on  the  opposite  side  to  that  which  has  been 
struck  (contre  coup),  and  occasionally  the  hemorrhage  does  not  occur 
for  days  of  weeks  after  the  injury  (traumatic  apoplexy),  a  matter  of 
considerable  importance  from  a  medicolegal  standpoint. 

The  symptoms  are  divided  into  three  periods,  the  first  or  the 
second  of  which,  however,  may  be  absent,  (i)  Temporary  uncon- 
sciousness from  concussion,  during  which  the  pulse  is  feeble  and 
consequently  the  bleeding  slight;  (2)  a  period  of  consciousness  that 


520  MANUAL    OF    SURGERY 

varies  according  to  the  size  of  the  vessel  injured,  from  a  very  brief 
period  to  a  number  of  hours,  during  which  the  pulse  grows  stronger 
and  the  hemorrhage  increases;  hence  (3)  secondary  unconsciousness 
due  to  compression,  which  comes  on  gradually  as  the  clot  increases 
in  size.  The  patient  becomes  stupid  and  finally  comatose;  paralysis, 
perhaps  preceded  by  twitching,  develops  in  one  center,  usually  the 
head  or  arm,  and  slowly  creeps  to  adjacent  centers  until  the  whole 
opposite  side  of  the  body  is  involved;  the  pupil  of  the  affected  side 
becomes  dilated  and  immobile  owing  to  the  extension  of  the  clot  to 
the  base  of  the  brain;  and  choked  disc  develops  on  each  side,  being 
more  marked,  however,  on  the  side  corresponding  to  the  hemorrhage. 
The  pulse  is  more  frequent  than  in  other  forms  of  compression  ow- 
ing to  the  loss  of  blood ;the  temperature,  particularly  on  the  para- 
lyzed side  rises;  and  in  case  of  fracture. blood  finds  its  way  exter- 
nally. Lumbar  puncture  reveals  the  cerebrospinal  fluid  clear  of 
blood.  Owing  to  the  period  of  consciousness  mentioned  above  sub- 
dural hemorrhage  has  been  confused  with  the  cerebral  form  of  fat 
embolism  (q.v.). 

The  treatment  is  trephining  one  and  one-fourth  inches  behind  the 
external  angular  process  of  the  frontal  bone,  on  a  level  with  the  upper 
margin  of  the  orbit,  thus  exposing  the  middle  meningeal  and  its 
anterior  branch;  if  the  clot  is  not  found,  a  second  opening  should  be 
made  at  the  same  level  just  beneath  the  parietal  eminence,  i.e.,  over 
the  posterior  branch  (Figs.  255  and  256).  The  side  to  be  trephined 
is  that  opposite  the  paralysis,  and  not  necessarily  the  side  on  which 
injury  to  the  scalp  or  skull  is  evident.  The  clot  is  removed  with  the 
linger  and  the  artery  secured  by  a  suture-ligature.  If  the  artery 
has  been  ruptured  where  it  lies  in  an  osseous  canal,  such  may  be 
plugged  with  wax,  gauze,  or  sterile  wood,  or  gently  crushed  with 
forceps.  The  only  means  of  diagnosticating  hemorrhage  from  a 
sinus  are  the  situation  of  the  injury,  and  possibly  the  slower  onset  of 
symptoms  owing  to  the  low  pressure  of  the  blood  in  the  sinus.  The 
means  of  controlling  hemorrhage  from  a  sinus  have  already  been 
indicated  (see  technic  of  cerebral  surgery).  The  mortality  of  ex- 
tradural hemorrhage  without  operation  is  90  per  cent.,  with  operation 
333^^  per  cent. 

Subdural  hemorrhage  arises  from  injuries  to  the  inner  wall  of 
the  venous  sinuses,  from  rupture  of  the  middle  meningeal  artery  if. 
the  dura  has  been  opened,  and  most  frequently  from  wounds  of  the 
middle  cerebral  or  its  branches. 

The  symptoms  are  those  of  concussion,  rapidly  merging  into 


HEAD 


;2I 


compression  owinji;  to  the  widely  dilTused  clot.  In  rare  instances  the 
clot  may  be  limited  and  give  localizing  symptoms.  Lumbar  puncture 
discloses  bloody  cerebrospinal  fluid. 

The  treatment,  if  the  clot  can  be  localized,  is  trephining  over  the 
region  indicated  by  the  symptoms,  removal  of  the  coagulated  blood, 
hemostasis  by  ligature  or  packing,  and  drainage.  In  other  cases 
bi-temporal  decompression  may  be  performed.  As  a  rule,  however, 
the  injury  is  widespread  and  but  little  can  be  accomplished  by 
operation. 

Cerebral  hemorrhage  due  to  trauma  is  accompanied  by  injuries 
so  diffuse  that  death  quickly  follows,  and  operation  is  indicated  only 
in  the  presence  of  locahzing  symptoms.     See  also  wounds  of  the  brain. 

Wounds  of  the  internal  carotid 
artery  within  the  skull  are  quickly 
fatal  if  the  wound  is  large,  but  if 
small,  recovery  sometimes  occurs 
with  the  development  of  an  aneu- 
rysmal varix  between  the  artery 
and  the  cavernous  sinus.  The 
treatment  is  ligation  of  the  com- 
mon carotid  in  the  neck. 

Intercranial  hemorrhage  in 
the  new-born  may  occur  during 
difficult  labor  and  after  the  applica- 
tion of  forceps,  from  overriding  of 
the  cranial  bones,  particularly  the 
parietal,  in  which  case  the  veins 
emptying  into  the  superior  longitudinal  sinus  are  torn. 

The  symptoms  are  irregular  respirations  or  asphyxia,  a  bulging, 
feebly  pulsating  anterior  fontanelle.  unequal  pupils,  and  usually 
convulsions;  lumbar  puncture  reveals  bloody  cerebrospinal  fluid. 
The  few  cases  that  survive  develop  idiocy,  epilepsy,  or  some  form  of 
birth  palsy  (Little's  disease),  e.g.,  spastic  hemiplegia,  or,  if  both  leg 
centers  are  involved,  spastic  paraplegia. 

The  treatment  is  removal  of  the  clots,  after  making  an  osteo- 
plastic flap  in  one  or  both  parietal  regions,  according  to  whether  the 
bleeding  is  unilateral  or  bilateral. 

Edema  of  tne  brain,  local  or  generalized,  may  be  associated  with 
any  other  form  of  cerebral  compression,  augmenting  its  symptoms. 
It  may  follow^  concussion,  contusion,  or  laceration  of  the  brain,  in 
which  event  the  symptoms  are  practically  identical  with  those  of 
hemorrhage;  absence  of  blood  in  the  fluid  obtained  by  spinal  punc- 


FiG.  264. — Pulsating  exopthalmus  re- 
sulting from  aneurysmal  varix  between 
internal  carotid  artery  and  cavernous 
sinus. 


522  MANUAL    OF    SURGERY 

ture  would  favor  the  diagnosis  of  edema.  Cerebral  edema  may  occur 
also  in  mitral  stenosis  and  in  lesions,  e.g.,  tumors,  interfering  with 
the  return  flow  of  blood  from  the  head.  It  sometimes  arises  in 
chronic  nephritis,  causing  unilateral  convulsions  or  paralysis,  which 
symptoms  have  been  misinterpreted  and  the  patient  operated  upon 
for  tumor  or  abscess  of  the  brain.  The  treatment  is  that  of  the  causa- 
tive lesion.  Regardless  of  the  cause  decompression  may  be  consid- 
ered in  any  case  in  which  life  is  threatened,  even  in  uremia. 

Wounds  of  the  brain  may  be  non-penetrating,  i.e.,  those  which 
do  not  communicate  with  the  exterior,  or  penetrating,  i.e.,  those 
associated  with  an  external  wound. 

Non-penetrating  wounds  are  caused  by  falls  and  blows,  and  may 
or  may  not  be  associated  with  simple  fracture  of  the  skull.  They 
vary  in  degree  from  a  limited  contusion  to  extensive  lacerations  or 
pulpification.  The  amount  of  hemorrhage  depends  upon  the  situa- 
tion and  extent  of  the  injury.  If  the  patient  recovers,  the  effused 
blood  may  be  absorbed  and  the  site  of  the  laceration  be  marked  by  a 
depressed  cicatrix,  or  the  extravasated  blood  may  become  organized 
as  a  brownish  adherent  layer  or  form  a  cyst.  In  other  cases  inflam- 
matory phenomena  supervene  and  cause  softening  of  the  brain  tissue, 
which,  if  not  extensive  or  involving  important  centers,  may  result  in 
complete  recovery.  In  more  serious  cases  the  inflammation  spreads 
to  the  meninges,  and  compression  of  the  brain  ensues  as  the  result 
of  edema  or  exudation.  It  is  generally  thought  that  cerebral  tissue, 
once  destroyed  is  never  regenerated;  if  the  functions  of  such  tissue 
reappear,  it  is  supposed  to  be  due  to  compensatory  action  of  neighbor- 
ing centers. 

The  S3anptoms  are  those  of  severe  concussion,  indeed  if  a  patient 
does  not  react  promptly  from  concussion,  contusion  or  laceration  of 
the  brain,  or  hemorrhage  is  probably  present.  Death  may  be  in- 
stantaneous if  the  vital  centers  are  involved.  Symptoms  of  com- 
pression, if  present  from  the  beginning,  indicate  depressed  fracture, 
or  extensive  hemorrhage  from  the  brain  tissue;  compression  coming 
on  later  is  due  to  bleeding  from  the  meningeal  vessels  or  sinuses,  or 
to  a  spreading  edema  or  inflammatory  exudate.  The  locaHzing 
symptoms  depend  upon  the  portion  of  brain  injured.  The  remote 
effects  are  those  of  concussion. 

The  treatment  depends  upon  the  symptoms.  If  concussion  is 
present  it  should  be  treated;  if  signs  of  compression  arise  the  skuU 
should  be  trephined  according  to  the  localizing  symptoms,  and  de- 
pressed bone  elevated,  hemorrhage  checked,  or  drainage  instituted, 
according  to  the  cause  of  compression. 


HEAD  523 

Penetrating  wounds  of  the  brain  are  caused  by  blows,  falls,  stabs 
and  gunshot  wounds  and,  excepting  rare  cases,  e.g.,  a  puncture 
through  an  open  fontanelle  or  foramen,  are  accompanied  by  fracture 
of  the  skull. 

The  S3rniptoms  are  those  of  compound  fracture  of  the  skull  with 
those  of  non-penetrating  wounds  of  the  brain.  In  punctures  such 
as  a  stab  wound,  in  which  important  centers  are  not  injured,  there 
may  be  no  symptoms  referable  to  the  brain,  as  the  injury  is  not  of 
such  a  nature  as  to  produce  concussion.  The  general  facts  regarding 
gunshot  wounds  are  given  in  chap.  x.  In  all  open  wounds  of  the 
brain  there  is  danger  of  septic  meningitis,  fungus  cerebri,  and  cerebral 
abscess.  If  proper  disinfection  can  be  carried  out  and  sterility 
maintained,  the  subsequent  course  is  the  same  as  in  non-penetrating 
wounds. 

The  treatment  is  that  of  shock,  and  exploration,  by  enlarging 
the  scalp  wound  if  necessary.  Depressed  fragments  of  bone  should 
be  removed,  the  opening  in  the  skull,  if  small,  enlarged  with  rongeur 
forceps,  hemorrhage  controlled,  accessible  foreign  bodies  removed, 
drainage  by  rubber  tube  instituted  when  infection  is  established 
or  debidement  has  been  imperfect,  the  dura  sutured  as  far  as  possible, 
and  the  patient  watched  for  symptoms  of  meningitis  or  abscess. 
Gushing  advocates  the  removal  en-bloc,  rather  than  piece  meal,  of 
the  area  of  cranial  penetration;  detection  of  in-driven  bony  fragments 
by  rubber  catheter  palpation  rather  than  by  finger  or  metalic  in- 
struments; the  use  of  dichloramine-T  in  oils  as  an  antiseptic;  the 
primary  closure  of  the  wound  as  the  ideal  procedure.  Gunshot 
fractures  of  the  skull,  even  with  clean  perforations,  require  trephining 
for  the  removal  of  depressed  portions  of  the  inner  table.  Tangential 
wounds  make  a  gutter  in  the  external  table  and  may  not  penetrate, 
but  the  inner  table  is  usually  fragmented,  and  the  fragments  are 
driven  into  the  brain.  The  best  means  for  locating  a  bullet  is  the 
X-ray.  If  a  probe  is  emloyed,  it  should  be  very  light,  e.g.,  the  Fluhrer 
aluminum  probe,  and  allowed  to  follow^  the  tract  by  gravity,  the 
head  being  placed  in  a  position  rendering  this  possible.  If  the 
bullet  cannot  be  found  by  a  careful  but  gentle  search,  or,  if  a  formid- 
able operation  would  be  necessary  to  remove  it,  even  if  localized  by 
the  X-ray,  it  should  be  allowed  to  remain  unless  causing  distinct 
symptoms. 

Hernia  cerebri  is  a  protrusion  of  the  brain  tissue  beneath  the 
scalp,  through  a  traumatic  defect  in  the  skull,  as  the  result  of  increased 
intracranial  pressure,  e.g.,  after  an  operation  for  an  irremovable 
tumor.     WTien  there  is  a  defect  in  the  scalp  the  condition  is  called 


524 


MANUAL    OF    SURGERY 


prolapse  of  the  brain.  It  pulsates,  has  an  impulse  on  coughing,  and 
may  be  partly  reducible,  causing  symptoms  of  compression  of  the 
brain.  According  to  the  cause  of  increased  intracranial  pressure,  it 
increases  or  decreases  in  size.  If  uncovered  by  scalp,  septic  men- 
ingitis is  likely  to  occur;  and  if  of  large  size,  gangrene  frequently 
results.  Prolapse  of  the  brain  should  not  be  confused  with  fungus 
cerebri  (Fig.  265),  which  is  simply  exuberant  and  edematous  granula- 
tions from  the  neuroglia,  as  the  result  of  wounds  of  the  brain.  Since 
the  latter  occurs  only  when  there  is  an  opening  leading  down  to  the 
brain,  care  should  be  taken  after  operation  to  suture  the  dura  when- 
ever possible;  when  a  portion  of  the  dura  has  been  destroyed,  the 
defect  may  be  closed  with  a  flap  of  pericranium,  sutured  in  place 

with  the  osteogenetic  sur- 
face outwards,  or  with  a 
piece  of  the  fascia  lata, 
fatty  side  in.  The  treat- 
ment of  hernia  and  pro- 
lapsus cerebri  is,  if  possible, 
the  removal  of  the  cause  of 
the  increased  intracranial 
pressure.  The  size  of  the 
hernia  may  be  reduced  by 
creating  a  hernia  on  the 
opposite  side,  i.e.,  by  a  de- 
compressive operation. 
Repeated  lumbar  punc- 
tures are  of  little  value. 
The  protruding  brain  should  be  protected,  and,  if  uncovered,  dressed 
with  sterile  gauze  to  prevent  septic  contamination.  Pressure  may  be 
dangerous,  and  amputation  should  be  employed  only  when  slough- 
ing has  occurred.  The  prognosis  is  unfavorable.  Fungus  cerebri  is 
treated  by  slicing  off  the  granulations,  or  by  cauterizing  them  with 
silver  nitrate.     The  condition  is  not  serious. 


Fig.  265.- 


-Fungus  cerebri  following  an  operation 
for  brain  tumor. 


DISEASE  OF  THE  CRANIUM  AND  ITS  CONTENTS 

For  diseases  of  the  cranial  bones  see  chapter  on  diseases  of  bone. 

A  meningocele  is  a  sac  of  cerebral  membranes  containing  cerebro- 
spinal fluid  and  protuding  through  a  congenital  opening  in  the  skull. 
It  occurs  most  frequently  in  the  middle  line,  midway  between  the 
foramen  magnum  and  the  posterior  fontanelle,  but  may  be  found 
also  at  the  root  of  the  nose,  at  any  of  the  fontanelles,  or  at  the  base 


HEAD 


3^3 


of  the  skull.  It  is  round,  translucent,  pedunculated,  and  reducible; 
and  it  has  an  impulse  on  coughing,  tiuctuates,  and  rarely  pulsates. 
In  meningocele,  as  well  as  in  encephalocele  and  hydrencephalocele, 
the  bony  defect  may  be  detected  by  palpation  and  the  X-ray. 
Spurious  meningocele  is  described  on  p.  501.  The  treatment  is 
excision  of  tht-  sac  and  closure  of  the  opening  in  the   membranes. 

Encephalocele  is  a  meningocele  containing  a  portion  of  the  brain. 
The  signs  are  the  same  as  those  of  meningocele,  except  that  the 
tumor  is  opaque,  pulsates  but  does  not  fluctuate,  and  causes  symp- 
toms of  pressure  when  reduced.  Occasionally  the  brain  tissue 
retracts  within  the  skull  and  the  tumor  becomes  a  meningocele 
which  in  rare  instances  may  undergo  spontaneous  cure  owing  to 
the  closure  of  the  opening.  The  treatment  is  excision  of  the  sac  and 
brain  tissue,  providing  no  important  center  is  involved. 

Hydrencephalocele  is  the  same  as  encephalocele,  except  that 
the  herniated  brain  tissue  contains  a  cavity  which  communicates 
with  the  ventricles.  The  swelling  is  large,  lobulated,  somewhat 
translucent,  and  rarely  pedunculated  or  reducible;  and  it  fluctuates, 
pulsates,  and  has  a  slight  impulse  on  coughing.  If  the  tumor 
contains  motor  centers  there  may  be  paralysis.  Hydrencephalocele 
is  not  amenable  to  treatment  and  is  always  fatal. 

Pneiimatocele  is  a  collection  of  air  between  the  pericranium  and 
the  skull,  the  result  of  a  spontaneous  or  pathological  perforation  of 
the  frontal  sinus  or  mastoid  cells.  Of  thirty-three  cases  reported, 
twenty-three  were  occipital  and  ten  frontal.  The  tumor  is  elastic, 
tympanitic,  pseudo-fluctuant,  and  often  partly  reducible.  The  treat- 
ment is  puncture  and  compression;  or  better  incision,  and  plugging  of 
the  opening  in  the  bone  with  antiseptic  wax.     Figs.  266  to  268 

Hydrocephalus  is  an  excess  of  fluid  in  the  ventricles  (internal 
hydrocephalus)  or  in  the  subarachnoid  space  (external  hydrocephalus) . 
The  term  external  hydrocephalus  has  been  loosely  applied  to  edema 
of  the  piaarachnoid,  porencephaly,  and  fluid  collections  following 
meningitis,  but  should  be  restricted  in  its  signification  to  the  rare 
cases  in  which,  owing  to  atrophy  or  lack  of  development  of  the 
brain,  there  exists  a  large  space  between  the  cerebral  cortex  and 
the  skull;  in  these  cases  surgical  treatment  is  not  indicated. 

Internal  hydrocephalus  may  be  congenital  or  acquired.  The 
congenital  (chronic,  idiopathic)  form  is  of  unknown  origin.  Sj'philis 
or  alcoholism  in  the  parents  has  been  held  responsible  for  a  few 
cases.  The  cranium  becomes  very  much  enlarged  (Fig.  269),  the 
superficial  veins  are  distended,  the  face  looks  small,  the  sutures 
and  fontanelles  are  wide  and  bulging,  and  the  child  is  defective 


526 


MANUAL    OF    SURGERY 


mentally.     Convulsions,    optic  atrophy,  and  paralyses  may  occur, 
and   death  usually  takes  place  early.     Sometimes  a  cracked  pot 


&0 


sound  may  be  obtained  on  percussion,  sometimes  fluctuation  may 
be  felt,  and  occasionally  the  head  is  translucent.  The  X-rays 
reveal  the  thinned  bone  and  cerebral  cortex,  the  wide  sutures  and 


HEAD 


527 


fontanelles,  and  the  dilated  lateral  ventricles.  Ventriculography 
has  its  greatest  value  in  the  diagnosis  of  internal  hydrocephalus. 
After  tapping  the  ventricle  and  withdrawing  20  c.c.  of  fluid  an  equal 
volume  of  air  is  introduced.  This  is  repeated  until  all  of  the  lluid 
is  withdrawn.  The  acquired  form  may  be  acute  (e.g.,  from  men- 
ingitis, breaking  of  an  abscess  into  the  ventricle)  or  chronic,  e.g., 
obstructive  when  from  adhesions  or  tumor  closing  the  aqueduct  of 


Fig. 


-Pneumatocele,  same  patient  as  Figs.  266  and  267. 


Sylvius  or  the  foramen  of  Majendie,  or  a  tumor  pressing  upon  the 
veins  of  Galen  or  the  straight  sinus,  and  communicative  when  caused 
by  increased  secretion  of  the  choroid  plexsus,  decreased  absorption 
by  the  arachnoid  villi,  or  both.  It  sometimes  follows  operation  for 
spina  bifida.  Dandy  suggests  the  differentiation  of  the  types  of 
hydrocephalus  by  the  intraventricular  injection  of  lo  c.c.  of  phen- 
olsulphonpthalene  when  12  to  20  per  cent,  should  be  excreted  in  the 


528  MANUAL    OF    SURGERY 

urine  the  following  2  hours;  less  than  this  indicates  diminished 
absorption  by  the  arachnoid  villi.  After  intraventricular  injection 
it  should  appear  in  the  spinal  fluid  within  i  to  3  minutes.  A  delay 
beyond  10  minutes  indicates  the  obstructive  type.  The  symptoms 
are  those  of  compression  of  the  brain,  with,  in  the  acute  variety, 
those  of  infection.  The  contour  of  the  head  is  not  altered  in  acute 
cases,  or  in  those  developing  after  ossification  of  the  sutures. 


Fig.   269. — Hydrocephalus.      Thu   circumference   of   the   head   was   twice   that   of   the 
chest.      Note  pressure  sore  on  the  scalp. 

The  treatment  of  acute  hydrocephalus  is  that  of  meningitis. 
Chronic  hydrocephalus  depending  upon  tumor  should  be  treated 
by  removal  of  the  tumor.  If  this  is  impossible,  reUef  from  pressure 
may  be  obtained  by  making  a  large  opening  in  the  skull.  Con- 
genital hydrocephalus  cannot  be  cured.  Elastic  pressure,  the 
injection  of  Morton's  fluid  (see  spina  biiida),  tapping  the  ventricles 
and  spinal  puncture  are  practically  useless.     The  lateral  ventricle 


HEAD  529 

may  be  puiutunu]  cither  at  one  side  of  a  large  anterior  fontanelle, 
or  by  making  a  small  trephine  opening  one  and  one-f(nirth  inches 
above  and  behind  the  external  auditory  meatus,  and  pushing  the 
needle  inwards  two  and  one-fourth  inches,  towards  a  point  two  and 
one-half  inches  above  the  opposite  meatus  (Keen).  When  due  to 
hypersecretion  Dandy  suggests  the  removal  of  the  choroid  plexsus 
after  opening  the  lateral  ventricle.  The  most  encouraging  results 
have  been  obtained  by  means  of  horse  hair  or  catgut  strands,  one 
end  of  which  is  introduced  into  the  lateral  ventricle  and  the  other 
placed  beneath  the  dura  or  beneath  the  skin,  thus  providing  per- 
manent drainage  of  the  ventricular  fluid  to  a  situation  where  it 
may  be  absorbed.  Payr  drains  the  ventricle  into  the  internal 
jugular  by  means  of  a  transplanted  vein  or  artery.  Gushing  drains 
the  spinal  theca  into  the  retroperitoneal  tissues  by  a  cannula  passed 
through  the  fifth  lumbar  vertebra.  Cotteril  in  one  case  secured 
improvement  by  opening  the  foramen  of  Majendie.  Stiles  ligates 
the  common  carotids,  one  several  weeks  after  the  other,  in  an  effort  to 
restore  the  normal  balance  between  the  secretion  and  the  absorption 
of  cerebrospinal  fluid. 

Microcephalus,  or  abnormal  smallness  of  the  cranium,  is  due 
to  defective  development,  and  is  usually  associated  with  idiocy. 
The  patient  should  be  referred  to  a  school  for  the  feeble  minded. 
Linear  craniotomy  is  useless  and  will  not  be  described. 

Intracranial  inflammation  may  involve  the  dura  (pachymen- 
ingitis) ,  the  arachnoid  and  pia  (leptomeningitis) ,  or  the  brain  (enceph- 
alitis). In  most  instances  both  the  membranes  and  the  brain  are 
involved  and  the  condition  is  called  meningitis  or  encephalitis,  al- 
though meningo-encephalitis  would  perhaps  be  the  best  term.  Under 
this  heading  should  be  included  also  infective  sinus  thrombosis. 

Pachymeningitis  externa,  i.e.,  inflammation  of  the  outer  layer 
of  the  dura,  is  due  to  injury,  syphilis,  or  to  diseases  of  the  cranial 
bones,  particularly  of  the  osseous  tissue  surrounding  the  middle 
ear.  In  the  simple  form  the  membrane  is  thickened,  perhaps 
causing  a  persistent  localized  headache.  In  the  suppurative  variety 
pus  collects  between  the  dura  and  the  bone,  and  the  symptoms  and 
treatment  are  identical  with  those  of  extradural  abscess. 

Pachjmieningitis  interna  may  be  due  to  extension  from  the 
outer  layer  of  the  dura  or  from  the  pia  and  arachnoid.  Pachy- 
meningitis interna  hemorrhagica  (hematoma  of  the  dura  mater)  is 
caused  by  the  rupture  of  vessels  in  a  vascular  layer  which  forms  on 
the  inner  surface  of  the  dura.     The  condition  is  generally  bilateral, 

and  is  found  most  frequently  in  the  insane,  alcoholic,  syphilitic, 
34 


53°  MANUAL    OF    SURGERY 

and  in  the  aged,  although  it  may  be  associated  with  infectious 
fevers  and  diseases  of  the  blood.  The  symptoms  are  those  of 
cerebral  irritation  and  slowly  progressing  compression,  perhaps 
with  localizing  phenomena.  The  treatment  is  trephining  on  iDoth 
sides  and  removal  of  the  subdural  clot. 

Leptomeningitis,  or  inflammation  of  the  pia-arachnoid,  may  be 
acute  or  chronic,  localized  or  diffused. 

Acute  leptomeningitis  may  be  primary,  e.g.,  in  wounds  (pyogenic 
organisms)  and  in  epidemic  cerebrospinal  meningitis  (diplococcus 
intracellularis  meningitidis),  but  it  is  most  frequently  secondary 
to  infective  diseases  of  the  scalp,  cranium,  and  face,  e.g.,  erysipelas, 
carbuncle,  caries,  necrosis,  and  middle  ear  disease,  or  to  pyemia, 
pneumonia,  typhoid,  influenza,  diphtheria,  gonorrhea,  anthrax, 
actinomycosis,  tuberculosis,  or  sun-stroke.  .  It  occurs  too  as  a 
terminal  infection  in  many  chronic  maladies,  including  chronic 
alcoholism  (pyogenic  organisms).  Thus  a  great  variety  of  bacteria 
may  be  responsible  for  the  condition.  The  inflammation  is  essen- 
tially the  same  as  in  other  parts  of  the  body.  The  subarachnoid 
space  becomes  distended  with  a  cloudy  or  purulent  fluid,  and  the 
brain  becomes  edematous  and  covered  with  lymph  and  frequently 
shows  small  hemorrhages.  Extension  to  the  meninges  of  the  cord 
is  very  apt  to  follow.  Should  recovery  occur,  the  patient  is  liable 
to  suffer  from  the  changes  which  occur  in  the  brain  tissue,  or  from 
adhesions  which  shut  off  the  ventricles  (hydrocephalus)  or  which 
form  at  the  cortex  or  base  of  the  brain  (epilepsy,  paralyses  of  the 
cranial  nerves,  etc.). 

The  symptoms  in  traumatic  cases  usually  come  on  within  two 
or  three  days,  although  there  is  a  subacute  form  in  which  the  onset 
may  be  delayed  for  a  number  of  days  or  even  weeks,  probably  the 
result  of  a  late  infection  by  way  of  the  blood  or  lymph  vessels. 
The  symptoms  are  those  of  (i)  sepsis,  viz.,  chills,  irregular  fever, 
and  the  changes  associated  with  fever;  (2)  those  of  irritation  of  the 
brain,  which  occur  in  the  early  stages,  viz.,  severe  headache,  vom- 
iting, stiff  neck,  rigidity  of  other  muscles  (producing  in  the  leg 
Kernig's  sign),  dehrium,  photophobia,  contracted  pupils,  hyper- 
esthesia, and  convulsions;  and  (3)  those  due  to  pressure,  which 
occur  during  the  terminal  stage,  viz.,  coma,  dilated  unequal  pupils, 
optic  neuritis,  strabismus,  paralyses  in  other  parts  of  the  body, 
slow  pulse,  and  stertorous  respirations.  Upon  lumbar  puncture 
the  cerebrospinal  fluid  spurts  out;  it  contains  many  polymorpho- 
nuclear leukocytes  in  septic  cases,  many  lymphocytes  in  tuberculous 
cases,  the  causative  bacteria,  and  no  dextrose. 


HEAD  531 

'I'lu'  treatment  is  to  i)lacc  Ihc  puticnt  in  a  quiet  darkened  room, 
l)ut  ice  to  the  head,  administer  laxatives  and  apply  wet  cups  to 
the  mastoid  (to  drain  the  mastoid  vein)  and  back  of  the  neck. 
Sedatives,  such  as  bromid  of  potassium,  are  used  in  the  early 
stages,  stimulants  in  the  final  stage.  Mercury  and  potassium  iodid 
are  often  employed.  In  epidemic  cerebrospinal  meningitis  Flexner's 
serum  has  proved  of  value.  Lumbar  puncture  may  be  used  to 
remove  pressure  temporarily;  the  ventricles  also  have  been  tapped 
for  the  same  indication.  Trephining  for  drainage  is  indicated  if 
the  process  is  localized,  and  has  been  employed  in  even  the  diffuse 
form,  with,  however,  very  little  encouragement,  the  opening  being 
made  in  the  occipital  bone  towards  the  base  of  the  brain  so  as  to 
drain  the  cisterna  magna. 

Chronic  leptomeningitis  may  follow  trauma  and  is  not  infre- 
quently seen  in  syphilitics  and  alcoholics.  The  membranes  are 
thickened  and  are  adherent  to  the  brain,  causing  persistent  local- 
ized headache,  tenderness,  and  sometimes  epilepsy.  The  treatment 
is  the  administration  of  sedatives  and  potassium  iodid,  or  if  these 
fail  trephining. 

Infective  thrombosis  of  the  venous  sinuses  may  be  due  to  pri- 
mary infection  in  compound  fractures  of  the  skull  or  in  the  acute 
infective  fevers,  but  is  usually  secondary  to  infections  of  the  ear, 
nose,  pharynx,  face,  orbit,  or  scalp,  the  primary  inflammation 
spreading  by  contiguity,  or  by  setting  up  a  phlebitis  which  extends 
inwards  to  the  sinuses.  In  two-thirds  of  the  cases  the  cause  is 
disease  of  the  middle  ear,  and  the  lateral  sinus  is  the  one  affected. 
Meningitis   and   brain   abscess   are   not   infrequent   complications. 

The  symptoms  are  due  to  (i)  the  infective  process  and  (2)  to 
the  thrombosis,  i.  The  infective  symptoms  are  those  of  sep- 
ticemia or  more  frequently  pyemia;  some  cases  resemble  typhoid 
fever,  in  others  pulmonary  symptoms  are  prominent  owing  to 
infection  of  the  lungs  with  emboli.  If  the  infection  spreads  to  the 
meninges,  there  will  be  irritation  or  compression  of  the  brain,  as 
indicated  under  meningitis.  2.  The  symptoms  due  to  the  throm- 
bosis vary  with  the  sinus  affected.  Thrombosis  of  the  lateral 
sinus  causes  pain,  tenderness,  and  edema  along  the  line  of  the  sinus, 
over  the  mastoid,  and  along  the  jugular  if  the  latter  is  invaded. 
There  will  be  a  history  of  suppurative  middle  ear  disease,  with 
perhaps  an  offensive  discharge  which  has  ceased  with  the  onset  of 
the  symptoms  of  sinus  thrombosis.  The  pneumogastric,  glosso- 
pharyngeal, and  spinal  accessory  nerves  may  be  paralyzed  by 
pressure    in    the    jugular    foramen.     Thrombosis    of    the    superior 


532  MANUAL   OF    SURGERY 

longitudinal  sinus  causes  pain,  tenderness,  and  edema  along  the 
sinus  and  over  the  forehead,  epistaxis,  and  possibly  convulsions 
from  irritation  of  the  motor  area.  Thrombosis  of  the  cavernous 
sinus  causes  exophthalmos,  edema  of  the  orbit  and  eyelids,  choked 
disc,  and  paralysis  of  the  third,  fourth,  ophthalmic  branch  of  the 
fifth,  and  sixth  cranial  nerves.  Thrombosis  of  the  petrosal  sinus 
gives  no  localizing  symptoms. 

The  treatment  of  thrombosis  of  the  lateral  sinus  due  to  middle 
ear  disease  is  to  clean  out  the  mastoid  (p.  568),  and  then  expose  the 
sinus  by  gouging  or  chiseling  away  the  bone  at  the  posterior  part 
of  the  opening.  Any  pus  in  the  groove  of  the  sinus  is  washed  away, 
and  an  attempt  is  made  to  confirm  the  diagnosis  by  palpating  the 
sinus  and  by  introducing  a  hollow  needle.  If  no  blood  flows  through 
the  needle  thrombosis  is  present,  if  blood  flows  through  the  needle 
it  should  be  withdrawn  until  the  point  is  just  within  the  sinus,  to 
make  sure  there  is  no  mural  thrombus.  After  the  diagnosis  has 
been  confirmed,  the  internal  jugular  vein  should  be  tied  below  any 
existing  thrombus  to  prevent  septic  dissemination.  The  sinus  is 
then  opened,  and  the  clot  removed  by  curetting  until  free  bleeding 
is  obtained,  which  is  easily  controlled  by  forcing  gauze  between  the 
sinus  and  the  bone.  If  the  jugular  is  involved  it  should  be  excised 
above  the  ligature  which  has  been  placed  on  it,  and  irrigation 
practised  from  the  opening  in  the  skull  through  to  that  in  the  neck. 
Both  wounds  should  be  packed  with  sterile  gauze.  Death  is  prac- 
tically certain  without  operation,  while  the  mortahty  after  operation 
is  about  50  per  cent.  Inflammation  of  the  longitudinal  sinus  should 
be  dealt  with  in  a  similar  way,  but  the  remaining  sinuses  of  the  head 
are  practically  inaccessible,  although  attempts  have  been  made 
to  drain  the  cavernous  sinus  through  an  opening  in  the  temporal 
fossa,  somewhat  like  that  used  to  expose  the  Gasserian  ganglion. 

Intracranial  abscesses  may  He  between  the  dura  and  the  skull 
(extradural),  between  the  dura  and  the  brain  (subdural),  or  in  the 
brain  substance  (cerebral  or  cerebellar).  The  causes  are  those  already 
indicated  under  intracranial  infl.ammation,  50  per  cent,  being  due 
to  chronic  suppurative  otitis  media. 

Extradural  abscess  causes  fever  with  or  without  chills,  edema  of 
the  scalp  over  the  abscess  (Pott's  puffy  tumor),  a  discharging  sinus  if 
due  to  bone  disease  or  compound  fracture,  localized  headache  and 
tenderness,  and  pressure  symptoms,  e.g.,  spasm  or  paralysis  if  over 
the  motor  area,  optic  neuritis  or  dilated  pupil  if  near  the  base,  etc. 
Coma  finafly  occurs,  owing  to  the  growth  of  the  abscess,  or  to  the 
extension  of  the  inflammation  to  the  meninges  and  the  brain.     The 


IIKAI)  S.U 

X-ray  may  locali/.o  the  abscess,  especially  if  it  is  due  to  disease  of  the 
])oiic.  Tlu'  Ircatmoit  is  drainage  by  enlarging  a  sinus,  if  such  exists, 
or  by  trephining.  If  due  to  middle  ear  disease,  the  mastoid  is 
opened  and  the  abscess  usually  found  by  following  a  sinus. 

Subdural  abscess  and  abscess  of  the  brain  ( annot  be  differen- 
tiated. Excepting  those  due  to  tuberculosis  and  pyemia,  the  abscess 
is  usually  single.  In  traumatic  cases  it  is  generally  under  that  por- 
tion of  the  scalp  which  has  been  struck,  but  it  may  be  on  the  opposite 
side  of  the  brain  just  like  contusions  and  lacerations.  Abscesses  due 
to  middle  ear  disease  are  most  common- in  the  temporosphenoidal 
lobe  and  next  in  the  cerebellum,  nine-tenths  being  within  a  circle 
whose  center  is  one  and  one-fourth  inches  above  and  behind  the  ex- 
ternal auditory  meatus,  and  whose  radius  is  one  and  one-fourth  inches. 
The  abscess  may  be  just  beneath  the  membranes,  or  it  may  lie  some 
distance  below  the  surface  of  the  brain,  the  infection  having  traveled 
along  the  blood  or  lymph  vessels. 

The  S3miptoms  may  be  either  acute  or  chronic,  and  are  due  to  the 
absorption  of  septic  products  and  to  compression  of  the  brain.  In 
acute  cases,  the  best  example  of  which  is  seen  a  few  days  after  a  com- 
pound fracture  of  the  skull,  there  are  severe  headache,  fever,  perhaps 
chills,  and  the  rapid  development  of  pressure  symptoms,  in  a  word 
the  symptoms  of  meningo-encephahtis,  from  which  the  condition 
cannot  be  distinguished  unless  there  are  localizing  symptoms.  In 
the  course  of  a  chronic  abscess  the  same  group  of  symptoms  may 
suddenly  arise,  owing  to  the  bursting  of  the  abscess  into  the  lateral 
ventricle  or  on  the  surface  of  the  brain.  Chronic  abscess  seldom 
begins  within  one  week  of  an  injury,  and  it  may  not  appear  for 
months  or  even  years.  In  a  typical  case  the  signs  of  septic  absorp- 
tion are  slight  or  absent,  thus  there  may  be  an  initial  rise  in  the 
temperature,  but  it  soon  falls  to  normal  or  subnormal,  although 
the  local  temperature  over  the  abscess  remains  elevated.  The 
symptoms  of  compression  come  on  slowly  in  the  course  of  weeks 
or  months.  They  are  persistent  headache,  often  most  marked 
(and  associated  with  tenderness)  over  the  abscess ;  cerebral  vomiting, 
which  is  distinguished  by  its  explosive  character,  the  absence  of 
nausea,  the  presence  of  a  clean  tongue,  and  by  the  fact  that  it  has  no 
relation  to  the  ingestion  of  food;  slow,  full  pulse;  mental  Jiebetude 
merging  into  coma,  with  Cheyne-Stokes  respiration  in  the  final 
stages;  optic  neuritis,  which  if  bilateral  is  more  marked  on  the  affected 
side;  dilated  fixed  pupil  on  the  diseased  side;  ptosis  or  strabismus; 
convulsions  or  paralyses  of  the  face,  arm,  or  leg;  interference  with  the 
special  senses;  and  vertigo,  ataxia,  etc.,  according  to  the  portion  of 


534  MANUAL    OF    SURGERY 

brain  involved  (see  cerebral  localization).  Localizing  symptoms  in 
abscess  of  the  temporosphenoidal  lobe  are  often  absent.  Sometimes 
the  abscess  can  be  demonstrated  by  X-ray  examination. 

■  The  diagnosis  of  chronic  abscess  from  acute  meningitis  is  made  by 
noting  that  the  latter  commences  a  few  days  after  injury,  that  it  is 
associated  -^-ith  fever,  delirium,  contracted  pupils,  photophobia,  and 
stiff  neck,  and  that  the  whole  course  is  very  acute.  Lumbar  punc- 
ture (q.v.)  is  of  diagnostic  value.  Mastoid  disease  alone  may  cause 
cerebral  s\Tnptoms,  but  opening  the  mastoid  will  cause  these  symp- 
toms to  subside.  Thrombosis  of  the  lateral  sinus  is  associated  with 
chills,  fever,  and  sweats,  and  there  are  local  evidences  of  thrombosis. 
Tumor  of  the  brain  comes  on  more  slowly  than  abscess,  but  presents 
earher  localizing  symptoms.  Uremia  may  cause  symptoms  very 
much  like  those  of  abscess. 

The  treatment  is  trephining,  according  to  the  localizing  symp- 
toms, and  drainage.  The  dura  may  be  opened  by  a  crucial  incision, 
which  will  be  all  that  is  needed  if  the  abscess  is  subdural.  If  it  lies 
beneath  the  cortex  the  livid  and  edematous  brain  will  bulge  into  the 
opening  and  there  will  be  absence  of  pulsation.  The  exact  site  of  the 
abscess  should  be  determined  by  a  grooved  director  or  trocar  and 
cannula,  when  a  pair  of  hemostatic  forceps  may  be  pushed  along  the 
exploring  instrument  into  the  abscess,  opened,  and  withdrawn. 
The  caA-ity  is  drained  by  means  of  a  double  rubber  tube,  around 
the  projecting  portion  of  which  gauze  may  be  packed  to  protect  the 
meningeal  cavity.  Curetting  and  irrigation  are  contraindicated. 
In  abscess  due  to  middle  ear  disease  the  mastoid  should  first  be 
opened  and  any  sinus  followed,  thus  perhaps  evacuating  an  extra- 
dural or  even  a  subdural  collection  of  pus.  If  the  abscess  is  in  the 
temporosphenoidal  lobe,  the  incision  in  the  soft  parts  may  be  ex- 
tended upwards,  and  the  skull  opened  about  three-fourths  of  an 
inch  above  the  posterior  root  of  the  zygoma,  on  a  Une  with  the  poste- 
rior border  of  the  bony  auditory  meatus.  Barker  advises  trephining 
one  and  one-fourth  inches  above  and  behind  the  external  auditory 
meatus.  For  abscess  of  the  cerebellum  the  trephine  is  made  below 
the  lateral  sinus,  midway  between  the  inion  and  the  mastoid,  al- 
though it  may  sometimes  be  reached  by  deepening  and  enlarging  the 
opening  which  has  been  made  in  the  mastoid. 

Intracranial  tumors  may  spring  from  the  interior  of  the  skull  or 
from  any  of  the  intracranial  tissues,  or  they  may  be  metastatic,  the 
primary  tumor  existing  in  some  other  portion  of  the  body.  In  this 
region  the  term  tumor  is  used  in  a  broad  sense,  and  includes  not  only 
neoplasms,  but  cysts  and  growths  due  to  parasites  and  the  infectious 


HEAD  535 

granulomata.  Speaking  in  round  numbers  t,t,}4  per  cent,  are 
sarcomata  (including  endothelioma,  psammoma,  and  glioma), 
25  per  cent,  tuberculous,  10  per  cent,  cysts  (usually  resulting  from 
old  blood  clots;  dermoids,  hydatids,  and  cysticerci  are  very  rare), 
5  per  cent,  secondary  carcinomata,  and  3  per  cent,  gummata.  Be- 
nign tumors  of  the  connective  tissue  type  are  exceptional;  adenoma 
is  occasionally  found  in  the  pituitary  body.  About  two-thirds  of  all 
tumors  are  situated  in  the  cerebrum,  one-third  in  the  cerebellum. 
They  are  more  frequent  in  males  than  in  females. 

The  symptoms  are  those  (i)  of  general  and  (2)  of  local  compres- 
sion, (i)  The  general  symptoms  are  constant  severe  headache,  which 
may  be  localized  to  the  site  of  disease,  and  associated  with  tender- 
ness if  the  tumor  be  superficial;  cerebral  vomiting  (p.  533);  gener- 
alized convulsions;  in  80  per  cent,  of  the  cases  optic  neuritis,  which  is 
usually  double  and  more  marked  on  the  affected  side  (unilateral 
choked  disc  indicates  a  tumor  near  the  back  of  the  orbit  on  the  same 
side) ;  limitation  of  the  visual  field  for  blue,  or  blue  blindness  (Gush- 
ing);  vertigo,  particularly  in  cerebellar  tumors;  inequahty  of  the 
pupils;  and  stupor  or  other  mental  symptoms,  finally  merging  into 
coma,  with  slow  pulse  and  Cheyne-Stokes  respirations.  The  tem- 
perature is  normal  or  subnormal  unless  there  is  a  complicating 
meningitis.  (2)  The  localizing  symptoms  are,  according  to  the  loca- 
tion of  the  tumor,  interference  with  the  special  senses,  spasm  or 
paralysis  of  any  of  the  eye  muscles  or  of  muscles  in  other  portions  of 
the  body,  anesthesia  (rare  unless  the  internal  capsule  is  involved), 
etc.  (see  cerebral  localization).  Localizing  symptoms  are  absent  if 
the  tumor  lies  in  a  silent  region.  Tumors  in  the  cerebello-pontine 
angle  may  cause  irritation  or  paralysis  of  the  third,  fifth,  sixth, 
seventh,  and  eighth  nerves.  The  symptoms  of  pituitary  tumors 
are  given  below. 

The  diagnosis  from  abscess  is  given  under  abscess  (vide  supra). 
Chronic  uremia,  and  occasionally  lead  poisoning,  may  cause  headache, 
vomiting,  convulsions,  and  optic  neuritis,  so  that  a  careful  examina- 
tion should  be  made  for  these  conditions.  Optic  neuritis  may  occur 
also  in  other  forms  of  toxemia,  e.g.,  from  arsenic,  alcohol,  diabetes, 
acute  infectious  fevers,  as  well  as  in  anemia,  cerebral  syphilis,  sinus 
thrombosis  and  all  forms  of  compression  of  the  brain.  Occasionally 
no  cause  for  it  can  be  found,  and  sometimes  it  is  hereditary.  Many 
cases  of  tumor,  particularly  in  the  silent  regions  of  the  brain,  are 
wrongly,  or  perhaps  we  should  say,  incompletely  diagnosticated  as 
hysteria,  neurasthenia,  migraine,  or  essential  epilepsy,  these  condi- 
tions really  being  secondary  to  the  cerebral  growth.     The  situation 


536  MANUAL    OF    SURGERY 

of  a  tumor  is  determined  by  the  localizing  symptoms  and  occasionally 
by  the  X-ray.  A  cortical  tumor  often  causes  tenderness  over  the 
growth  and  a  local  rise  in  the  temperature,  and  is  not  associated  with 
anesthesia.  Multiple  tumors,  of  which  the  most  frequent  are 
the  tuberculous,  metastatic,  and  gummata,  may  be  suspected  if 
widely  separated  centers  are  involved.  The  size  of  the  tumor  may 
be  indicated  by  the  number  of  centers  involved  and  the  degree  of 
compression.  The  nature  of  the  tumor  can  rarely  be  foretold. 
Those  which  most  frequently  follow  injury  are  sarcomatous.  Tuber- 
culous masses  are  apt  to  occur  before  the  twentieth  year,  and  to  be 
associated  with  tuberculosis  elsewhere;  the  patient  may  react  to  one 
of  the  tuberculin  tests,  and  tubercles  on  the  choroid  are  occasionally 
seen  with  the  ophthalmoscope.  The  history  of  syphilis  or  of  a 
primary  malignant  tumor  in  some  other  portion  of  the  body  may  aid 
in  arriving  at  a  correct  diagnosis,  as  may  also  the  Wassermann  test. 
Lumbar  puncture  may  be  of  service,  but  only  a  small  quantity  of  fluid 
should  be  withdrawn,  as  several  fatalities  have  followed  the  escape 
of  a  large  amount,  probably  owing  to  impaction  of  the  brain  stem  in 
the  foramen  magnum. 

The  prognosis  is  exceedingly  gloomy.  Excepting  the  gummata, 
death  is  inevitable  without  operation,  and  almost  95  per  cent,  are 
inoperable.  In  25  per  cent,  of  those  subjected  to  exploration  the 
tumor  is  not  found,  and  the  operative  mortality  is  about  ssji  per 
cent,  for  cerebral  tumors  and  60  per  cent,  for  cerebellar  tumors. 
Of  those  which  survive  the  removal  of  a  malignant  growth,  prac- 
tically all  will  be  the  victims  of  recurrence.  The  damage  to  the 
nervous  centers  caused  by  the  tumor,  even  if  it  has  been  safely 
removed,  is  usually  permanent. 

The  treatment,  at  first  is  usually  the  administration  of  potassium 
iodid,  with  the  hope  that  the  growth  may  be  syphilitic.  If  no  im- 
provement is  noticed  within  six  weeks,  operation  should  be  under- 
taken. If  the  Wassermann  reaction  is  absent,  one  may  dispense 
with  this  prehminary  treatment.  The  skull  over  the  area  indicated 
by  the  symptoms  is  opened  by  an  osteoplastic  flap  at  least  three  or 
four  inches  in  diameter.  If  the  patient's  condition  is  poor,  the 
flap  may  be  replaced  and  the  operation  completed  after  several  days 
(operation  in  two  stages).  The  dura  is  opened  as  indicated  in  the 
chapter  on  technic,  and  the  tumor  enucleated  with  the  finger  or 
handle  of  a  knife,  after  incising  the  brain  tissue  if  the  tumor  be 
subcortical.  The  cavities  resulting  from  the  removal  of  tumors 
or  cysts  may  be  filled  with  transplanted  fat,  enough  fascia  being 
attached  to  close  the  dural  defect.     If  the  tumor  cannot  be  removed. 


HEAD 


537 


the  dura  should  he  allowed  to  j^aj),  and  the  seal])  sutured  after  stri])- 
jiing  the  hone  from  the  inner  side  of  the  osteoplastic  flap,  so  that  at  least 
relief  from  jjressure  may  be  obtained.  When  the  growth  cannot  be 
localized  or  is  known  to  be  irremovable  decompression  may  be  delib- 
erately undertaken  to  relieve  headache  and  vomiting,  prevent 
blindness,  and  prolong  life.  In  such  cases,  if  the  tumor  be  cerebral 
the  bone  and  dura  beneath  the  right  temporal  muscle  (the  speech 
center  is  on  the  left  side)  should  be  removed,  through  a  straight 
longitudinal  incision.  Cerebellar  decompression  is  made  by  remov- 
ing the  bone  and  dura,  on  each  side,  from  the  superior  curved  line  of 
the  occipital  bone  to  the  foramen  magnum,  after  reflecting  the  soft 
tissues  as  a  flap. 

Tumors  of  the  pituitary  body  (hypophysis  cerebri) ,  in  addition  to 
the  general  symptoms  of  brain  tumor,  may  cause  bitemporal  hemi- 
anopsia (primary  atrophy  of  the  nasal  half  of  each  optic  disc)  from 
pressure  on  the  optic  chiasm,  and,  as  shown  by  the  X-ray,  excavation 
of  the  sella  turcica.  As  with  tumors  of  the  thyroid  gland  the  function 
of  the  hypophysis  may  be  increased  or  decreased.  Hyperpituitarism 
(increased  activity  of  the  anterior  lobe)  causes  gigantism  in  youth, 
acromegaly  (q.v.)  in  adults.  Hypopituitarism  (decreased  activity 
of  the  posterior  lobe)  causes  dystrophia  adiposogenitahs,  i.e.,  small 
stature,  infantile  genitalia  (with  impotence  in  men,  amenorrhea  in 
women),  hypotrichosis,  obesity,  drowsiness,  insensitivity,  slow  pulse 
and  respirations,  low  blood  pressure,  subnormal  temperature,  and 
high  tolerance  for  carbohydrates,  i.e.,  it  is  difficult  or  impossible  to 
produce  glycosuria  by  giving  large  quantities  of  sugar.  Little  is 
known  of  the  effects  of  decreased  activity  of  the  anterior  lobe  and 
increased  activity  of  the  posterior  lobe.  The  tumor  may  be  removed 
from  the  front,  after  osteoplastic  resection  of  the  lower  portion  of  the 
frontal  bone,  ligation  of  the  longitudinal  sinus,  and  elevation  of  the 
frontal  lobes;  from  the  side,  as  in  the  operation  for  resection  of  the 
Gasserian  ganglion;  through  the  body  of  the  sphenoid,  after  reflecting 
the  nose  to  one  side  and  removing  the  turbinate  bodies  and  vomer; 
or  by  one  of  the  several  modifications  of  these  operations.  Care  is 
taken  not  to  excise  the  entire  gland,  as  complete  ablation  results  in 
cachexia  hypophyseopriva  and  death. 

Epilepsy,  from  an  etiologic  and  therapeutic  standpoint,  may  be 
divided  into  two  forms,  the  idiopathic  and  the  symptomatic.  When 
no  cause  can  be  determined  the  disease  is  called  idiopathic,  or  essen- 
tial, and  surgical  treatment  is  not  indicated.  It  is  true,  however 
that  operations,  e.g.,  decompression  (Kocher),  ligation  of  tha  longi- 
tudinal   sinus    (Delangeniere),    carotid,    or    vertebral    artery,    and 


538  MANUAL    OF    SURGERY 

removal  o,f  the  cervical  sympathetic  ganglia,  have  been  recommended 
for  this  disease,  but  such  are  generally  regarded  in  the  same  light  as 
an  accident,  a  severe  shock,  or  in  fact  an  operation  in  any  portion  of 
the  body,  which  is  occasionally  followed  by  a  temporary  improvement 
in  the  convulsions.  Secondary,  or  symptomatic  epilepsy,  may  be 
divided  into  four  varieties.  ■  (i)  Syphilitic  and  (2)  toxic  epilepsy 
(e.g.,  due  to  plumbism,  nephritis,  diabetes,  alcoholism)  must  be 
treated  medically.  (3)  Peripheral  sources  of  irritation,  such  as 
phimosis,  carious  teeth,  ovarian  disease,  etc.,  should  be  removed 
with  the  hope  that  the  disease  may  be  reflex.  (4)  Those  cases  de- 
pending upon  a  definite  lesion  of  the  brain  or  its  coverings,  e.g., 
injury  to  the  scalp,  skull,  or  brain,  or  tumor,  abscess,  hemorrhage, 
localized  meningitis,  foreign  bodies,  adhesions  of  the  membranes, 
cicatrices  in  the  brain,  degenerative  changes  in  the  cortex,  etc.,  are 
usually /(?ca/,  or  Jacksonian,  in  type,  i.e.,  the  spasm  affects  one  group 
of  muscles  only  and  is  not  associated  with  unconsciousness,  or  it 
begins  in  one  group  of  muscles  and  terminates  in  a  generalized  con- 
vulsion with  unconsciousness.  Such  cases  always  demand  explora- 
tion and  removal  of  the  source  of  irritation.  Occasionally  simple 
excision  of  a  scar  in  the  scalp,  particularly  if  it  be  tender,  the  seat  of 
an  aura,  or  if  pressure  upon  it  produces  a  fit,  will  result  in  cure,  even 
when  the  convulsions  are  not  focal  in  character.  If  on  exploration 
no  lesion  can  be  found,  the  center  which  initiates  the  convulsion  may 
be  accurately  localized  by  electricity  and  excised.  The  resulting 
paralysis  may  involve  neighboring  centers  from  edema,  but  such  is 
only  temporary,  and  even  the  parts  supplied  by  the  excised  center 
often  resume  their  functions.  The  means  for  preventing  adhesions 
after  operations  of  this  character  have  already  been  mentioned. 
When  indicated,  operation  should  be  performed  early,  as  in  late 
cases  the  convulsions  may  continue  from  the  development  of  an 
epileptic  habit,  even  after  the  cause  has  been  removed.  Apart  from 
this,  recurrences  may  be  due  to  the  redevelopment  of  adhesions  or 
cicatrices,  so  that  recovery  is  seldom  permanent,  although,  as  indi- 
cated above,  temporary  improvement  may  follow  any  operation. 

Inveterate  headache,  particularly  when  localized  and  severe, may 
be  due  to  one  of  the  causes  mentioned  above  under  focal  epilepsy. 
If  unrelieved  after  a  thorough  trial  of  medicinal  measures,  trephining 
and  exploration  is  indicated. 

Insanity  and  arrest  of  development,  when  of  traumatic  origin 
may  occasionally  be  benefited  by  removal  of  any  existing  lesion  if 
such,  e.g.,  a  depression  in  the  skull,  can  be  localized. 


CHAPTER  XXII 


which  can  be  felt 


SPINE 

Spinal  Localization.— The  first  bony  prominence 
beneath  the  occiput  is  the  forked  spine  of  the 
axis.  The  next  prominent  spine  is  the  seventh 
cervical,  although  frequently  the  sixth  cervi- 
cal or  the  first  dorsal  is  equally  prominent, 
and  in  the  infant  the  first  dorsal  is  regularly 
more  prominent.  Generally  the  third 
lumbar  spine  is  a  little  more  prominent  than 
its  neighbors.  A  line  passing  through  the 
inner  extremities  of  the  spines  of  the  scapulas 
crosses  the  third  dorsal  spine;  through  the 
inferior  extremities  of  the  scapulae,  the 
seventh  dorsal;,  through  the  highest  points 
of  the  iliac  crests,  the  fourth  lumbar ;  through 
the  posterior  superior  spines  of  the  ilia,  the 
first  sacral  spine.  The  bodies  of  the  verte- 
brae may  be  palpated  through  the  mouth 
as  far  as  the  fifth  cervical  and  occasionally 
lower;  the  anterior  surface  of  the  sacrum 
and  coccyx  through  the  rectum.     That  sec- 


FiG.  270. — Relations  of  the  cord,  the  membranes, 
and  the  nerves  with  the  spinous  processes  (after  Marion). 
The  spinal  cord  extends  to  the  level  of  the  spinous  pro- 
cess of  the  first  lumbar  vertebra  in  men,  to  the  second 
in  women,  to  the  third  in  infants.  The  cervical  cord 
terminates  at  the  sixth  interspinous  space,  the  dorsal  cord 
at  the  ninth  dorsal  spine,  the  lumbar  cord  at  the  twelfth 
dorsal  spine. 

The  dura  terminates  at  the  first  sacral  spine. 

The  level  of  the  spinal  segments  is  determined  as 
follows:  In  the  cervical  region,  add  one  to  the  number  of 
a  given  spinous  process,  thus  the  third  cervical  segment 
lies  opposite  the  second  cervical  spine;  in  the  superior 
dorsal  region,  add  two;  from  the  sixth  to  the  eleventh, 
add  three;  the  inferior  part  of  the  eleventh  dorsal  spine, 
the  subjacent  interspace,  and  the  twelfth  spine  cor- 
respond to  the  last  three  lumbar  segments;  the  subjacent 
interspace  and  the  first  himbar  spine  correspond  to  the 
sacral  segments. 

In  the  cervical  region,  the  nerves  emerge  above  the 
corresponding  vertebras  (the  seventh  nerve  emerges  above  the  seventh  cervical  vertebra) ; 
in  the  dorsal  and  lumbar  regions,  they  emerge  below  the  corresponding  vertebrae.  In 
the  cervical  and  lumbar  regions,  the  foramina  are  on  a  level  with  the  spine  of  the  vertebra 
which  limits  them  above;  in  the  dorsal  region,  they  are  on  a  level  with  the  spine  of  the 
vertebra  next  above  that  which  limits  them  superiorly. 

539 


540 


MANUAL   OF    SURGERY 


tion  of  the  cord  from  which  spring  the  fibers  forming  a  single  spinal 
nerve  is  called  a  segment;  it  corresponds  to  the  nerve  to  which  it 
gives  origin,  but  does  not  He  opposite  the  vertebra  of  Hke  name 
and  number,  owing  to  the  fact  that  the  cord  is  much  shorter  than 


2C' 


4-C 


2  D 


.-2and3  S. 


2L 


3L 


'-5L 


Pig.  271. — Sensory  distribution  of  the  spinal  segments,  combined  principally  from 
the  diagrams  of  Bolk.  The  zones  corresponding  to  the  distribution  of  the  cervical  and 
lumbar  segmenst  are  marked  in  red.  Every  cutaneous  area  is  supplied  not  by  one,  but 
by  three  segments,  so  that  an  injury  to  one  sensory  root  might  be  followed  by  but  little 
sensory  disturbance.  It  is  therefore  necessary  to  localize  a  lesion  at  the  level  of  the 
highest  nerve  root  corresponding  with  the  highest  cutaneous  zone  attacked. 

the  spinal  canal  (Fig.  2  70) .  A  lesion  involving  all  the  contents  of  the 
spinal  canal  at  a  given  level  destroys  not  only  the  segment  at  that 
level,  but  also  the  nerves  which  run  alongside  of  it,  thus  a  fracture 
at  the  level  of  the  twelfth  dorsal  vertebra  might  destroy  not  only  the 


SPINE  541 

cord  at  that  level,  but  also  the  spinal  nerve  as  high  as  the  twelfth 
dorsal.  A  lesion  in  the  cord  is  localized  by  the  sensory,  motor,  and 
trophic  symptoms,  and  by  the  alterations  in  the  reflexes.  These  symp- 
toms correspond  to  an  exaltation  (hyperesthesia,  spasms,  increased  re- 
flexes), or  an  abohtion  of  the  functions  of  the  spinal  segments  (anesthe- 
sia, paralysis,  loss  of  reflexes),  according  to  the  nature  and  degree  of 
the  lesion.  Total  destruction  of  one  segment  causes :  anesthesia  of  the 
skin  suppHed  by  that  segment  and  all  lower  segments,  with  frequently 
a  narrow  band  of  hyperesthesia  immediately  above,  from  irritation 
of  the  nerve  roots  at  that  level ;  paralysis  of  the  muscles  supplied  by 
the  destroyed  segment  and  all  lower  segments;  trophic  changes  in  the 
parts  suppHed  by  the  destroyed  segment,  and  as  a  rule  in  the  parts 
supplied  by  the  lower  segments  owing  to  descending  degeneration 
(in  the  absence  of  descending  degeneration  trophic  changes  in  the 
parts  supplied  by  the  lower  segments  need  not  occur) ;  and  absence 
of  the  superficial  and  deep  'reflexes,  which  may,  however,  reappear  if 
the  cord  below  the  lesion  remains  intact.  Priapism  from  vasomotor 
paralysis  may  occur  in  lesions  of  any  part  of  the  cord ;  it  occurs  also 
from  irritation  of  the  erection  center  in  the  sacral  cord.  Diabetes 
likewise  may  occur  after  a  total  transverse  lesion  of  any  portion  of 
the  cord.  Complete  unilateral  lesions  cause  paralysis  upon  the 
same  side  and  anesthesia  upon  the  opposite  side  {Brown-Sequard 
paralysis) . 

A  study  of  Fig.  271  will  aid  in  the  localization  of  a  cord  lesion 
according  to  the  sensory  symptoms.  Practically  all  muscles  are 
innervated  not  by  one  but  by  several  segments.  In  the  following 
table  the  muscles  and  reflexes  are  listed  with  the  highest  segment 
concerning  them,  since  it  is  in  that  segment  a  lesion  must  be  local- 
ized if  the  muscle  is  completely  paralyzed. 


Segment.  Muscles. 


Reflex. 


Rectus  capitis  anticus  major  (C.  1-4). 

Rectus  capitis  anticus  minor. 

Rectus  capitis  posticus  major  and  minor. 

Geniohyoid  (C.  1-2). 

Superior  and  inferior  oblique  (C.  1-2). 

Complexus  (C.  1-3). 


Longus  colli  (C.  2-8). 
Sternomastoid. 
Subhyoids  (C.  2-2,). 
Splenius. 


542 


MANUAL   OF    SURGERY 


Segment. 


^Muscles. 


Reflex. 


C.  3  Levator  angulae  scapulae  (C.  3-5). 

Trapezius  (C.  3-4). 

Diaphragm  (C.  3-5). 

Total  lesions  at  or  above  this  level  are  usually 
immediately  fatal,  as  respiration  can  be  main- 
tained only  by  the  stemomastoids  and  superior 
part  of  the  trapezii. 


C.  4  Scaleni  (C.  4-D.  i). 

Teres  minor  (C.  4-5).) 
Rhomboid  (C.  4-5). 


Pupillary  (C.  4-D.  i). 


Supra-  and  infraspinatus  (C.  5-6). 

Deltoid  (C.  5-7). 

Serratus  magnus  (C.  5-8). 

Subclaxaus  (C.  5-6). 

Brachialis  anticus  (C.  5-6). 

Supinator  longus  and  brevis  (C.  5-7). 

Biceps. 

In  total  lesions  just  below  this  level  the  dia- 
phragm is  not  paralyzed  but  coughing  is  im- 
possible so  that  a  bronchitis  quickly  proves 
fatal;  the  upper  e.xtremities  assume  a  char- 
acteristic position,  abduction  and  external  rota- 
tion of  the  arm  with  flexion  and  supination  of  the 
forearm,  owing  to  the  unapposed  action  of  the 
muscles  just  enumerated. 


Scapular  (C.  5-D.  i). 
Supinator  longus. 
Biceps. 


C.  6  Pectoralis  major  (C.  6-D. 

Pronator  radii  teres. 
Extensors  of  wrist  (C.  6-S 
Triceps  (C.  6-7). 
Teres  major  (C.  6-7). 
Latissimus  dorsi  (C.  6-8). 
Subscapularis  (C.  6-7). 


2). 


Triceps. 
Posterior  wrist. 


Anterior  wrist. 


C.  7  ,  Pectoralis  minor  (C.  7-D.  2). 

I  Coraco-brachialis  and  anconeus  (C  7-S). 
!   Superficial  flexors  of  fingers. 
Pronators  of  wrist. 
-       Extensors  of  fingers. 

I  Muscles   of    thenar   and    h)q>othenar    eminences 
j    (C.  7-D.  i). 

I  In  a  total  lesion  just  below  this  segment  the  flexors 
of  the  wrist  and  intrinsic  muscles  of  the  hand  are 
the  only  muscles  of  the  upper  extremity  paralyzed. 


C.  8  Flexors  of  wrist. 

Interossei  and  lumbricales  (C.  8-D.  i). 


Palmar. 


SPINE 


543 


SiiGiiENT.  Muscles. 


D.  I  Intcrcostals  (D.  1-12). 

Erector  spinie  (D.  i-L.  5). 
I  Below  this  level  the  arms  escape  paralysis. 


RiCfLEX. 


D.  2-12         Rectus  abdominis  and  external  oblique  (D.  5-12). 

Internal  oblique  and  transversalis  (D.  7-L.  i). 

Paralysis  of  these  muscles  interferes  with  cough- 
ing, defecation  and  all  straining  movements. 
Severe  meteorism  may  develop  and  interfere  with 
respiration. 

L.  I  Quadratus  lumborum  (T>.  1-2). 

Cremaster. 
Psoas  magnus  (L.  1-3). 

L.  2  Iliacus. 

Quadriceps  (L.  2-4). 
j  Pectineus. 
Sartorius  (L.  2-3). 
Adductors  of  thigh  (L.  2-4). 
In  lesions  below  this  level  the  lower  limbs  are  not 
completely  paralyzed. 


Epigastric  (D.  4-7). 
Abdominal  (D.  9-12). 


Cremasteric  (L.  1-2). 


L.  3 


Internal  rotators  of  thigh. 
Adductors  of  thigh  (L.  3-4). 


Patellar. 


L.  4  '  Flexors  of  knee  (L.  4-5). 

Extensors  of  ankle  (tibialis  anticus,  etc). 
Gluteus  medius  and  minimus  (L.  4-5). 
Flexors  of  ankle  (calf  muscles)  (L.  4-S.  2). 
Extensors  of  toes  (L.  4-S.  i). 


Gluteal. 


L.  5  i  External  rotators  of  thigh. 

Gluteus  maximus  (L.  5-S.  i). 
Peronei  (L.  5-S.  3). 
Flexors  of  toes  (L.  5-S.  2). 


S.  1-2 


Small  muscles  of  foot. 


Ankle  clonus. 
Plantar. 


3-5  Levator  and  sphincter  ani  (S.  3-4). 

Bladder  (S.  3-4). 

Perineal  muscles  (S.  4-5). 

In  all  total  lesions  of  the  spinal  cord  and  of  the 
Cauda  equina  the  bladder  and  rectum  are  para- 
lyzed, causing  retention  and  later  dribbling  of 
overflow  in  the  former,  and  incontinence  in  the 
latter. 


Anal. 

Vesical. 

Erection  of  penis. 


544  MANUAL    OF    SURGERY 

Laminectomy,  or  removal  of  the  laminse  of  the  vertebrae,  may  be 
performed  for  exploration,  wounds  or  compression  of  the  cord,  section 
of  the  sensory  roots,  or  for  diseases  of  the  bones.  A  straight  incision 
is  made  over  the  spinous  processes;  the  laminae  exposed  by  separating 
the  muscles  from  the  bone  with  a  rougine;  the  bleeding  controlled  by 
gauze  sponges,  held  beneath  the  retractors  which  separate  the  wound; 
the  spinous  processes  removed  with  rongeur  forceps;  the  laminae 
excised  with  bone-cutting  forceps,  chisel,  or  saw;  the  contents  of  the 
spinal  canal  examined;  the  dura  opened,  if  necessary,  by  a  longitudi- 
nal incision,  using  the  same  precautions  as  in  opening  the  dura  of  the 
brain;  the  cord  examined,  being  very  careful  not  to  exert  undue  com- 
pression; the  dura  sutured  with  fine  catgut,  without  drainage  when- 
ever possible;  and  the  muscles  approximated  with  catgut  and  the 
skin  with  silkworm  gut,  superficial  drainage  being  employed  for 
twenty-four  hours,  or  longer  if  there  is  infection.  Osteoplastic  resec- 
tion, with  the  base  of  the  flap  above  or  on  one  side,  is  more  laborious 
and  no  more  useful.  One  need  not  fear  to  make  a  large  exposure, 
as  such  does  not  permanently  weaken  the  spine.  Braces  or  casts 
are  seldom  required  after  operation.  The  dangers  of  infection  are  no 
greater  than  in  the  skull,  chest,  or  abdomen,  and  the  escape  of  cere- 
brospinal fluid  seems  to  do  no  harm. 

Resection  of  the  posterior  roots  of  the  spinal  cord  is  commonly 
called  Foerster's  operation,  although  it  was  lirst  suggested  by  Dana. 
The  operation  has  been  performed  for  intractable  pain  of  various 
sorts,  including  the  gastric  crisis  of  tabes,  and  for  athetosis,  spastic 
paraplegia,  and  other  forms  of  spasticity,  the  idea  being  to  break 
the  reflex  arc  of  the  affected  muscles.  Laminectomy  is  performed, 
the  dura  opened,  and  the  roots  isolated  separately  and  divided.  The 
location  of  the  pain  or  the  spasticity  determines  the  roots  to  be 
sacrificed.  In  order  not  to  induce  complete  anesthesia  and  flaccidity 
in  the  affected  region,  not  more  than  two  of  the  three  sensory  roots 
presiding  over  a  given  area  should  be  severed.  For  spastic  paraplegia 
Foerster  advises  division,  on  both  sides,  of  the  second,  third,  and 
fifth  lumbar,  and  the  second  sacral.  The  seventh  to  the  tenth  dorsal 
roots  on  both  sides  have  been  divided  for  gastric  crises  in  locomotor 
ataxia.  Other  combinations  can  be  worked  out  from  Fig.  271  and  the 
table  on  p.  541.  The  operation  has  given  satisfactory  results  in 
some  cases;  in  others  it  has  not  secured  the  desired  result.  In  at 
least  one  case  a  Brown-Sequard  paralysis  followed. 

Spinal  puncture  (subarachnoid)  may  be  made  anywhere  between 
the  lower  end  of  the  cord  and  the  lower  end  of  the  dural  sac  (Fig.  270), 
but  the  favorite  spot  is  just  below  the  fourth  lumbar  vertebra.     The 


SPINE  545 

back  is  bent  forward,  the  left  index  finger  placed  on  the  selected 
spinous  process,  the  needle  (three  or  four  inches  long,  i  to  2  mm.  in 
diameter,  and  containing  a  stylet)  entered  just  below  and  to  the  out- 
side of  the  finger  and  pushed  slightly  inwards  and  upwards  for  from 
3^^  to  3  inches,  according  to  the  age  of  the  patient  and  the  thickness 
of  the  tissues,  the  stylet  withdrawn,  and  the  fluid  collected  in  a  sterile 
test  tube. 

Spinal  puncture  has  been  employed  for  anesthetic  (see  anesthesia) 
therapeutic,  and  diagnostic  purposes.  The  therapeutic  indications 
are  to  relieve  pressure,  e.g.,  in  cerebrospinal  meningitis  and  compres- 
sion of  the  brain,  and  to  inject  medicaments,  e.g.,  antitoxins,  salvar- 
sanized  serum,  etc.  For  diagnostic  purposes  not  more  than  5  cc.  of 
the  fluid  in  a  child,  10  cc,  in  an  adult,  should  be  withdrawn,  as  a 
few  cases  of  collapse  after  the  withdrawal  of  a  large  quantity  have 
been  reported.  Headache  and  a  rapid  fall  in  the  spinal  fluid  pressure 
are  indications  to  stop  the  procedure.  A  dry  tap  usually  indicates 
that  the  needle  is  not  within  the  dural  sac.  Normal  cerebrospinal 
fluid  is  clear,  colorless,  alkaline,  has  a  specific,  gravity  of  from  1002  to 
loio,  and  contains  chlorids,  a  trace  of  protein,  o.i  per  cent,  of  glucose 
(or  dextrose),  and  very  few  leukocytes  and  endothelial  cells  (from 
I  to  10  per  c.  mm.).  It  escapes,  when  the  patient  is  recumbent, 
under  a  pressure  of  from  5  to  7.5  mm.  of  mercury.  The  specific 
gravity  is  increased  in  meningitis,  the  pressure  in  meningitis  and  all 
forms  of  compression  of  the  brain  (except  when  the  fluid  accumulates 
above  a  closed  foramen  of  Majendi  or  aqueduct  of  Sylvius,  or 
when  the  communication  between  the  subarachnoid  spaces  of  the 
brain  and  cord  is  obstructed) ,  the  protein  in  meningitis,  hydrocepha- 
lus, acute  infectious  diseases,  subarachnoid  hemorrhage,  and  in 
syphihtic  and  parasyphilitic  affections  of  the  cerebrospinal  tract. 
Noguchi's  globulin  test  is  positive  in  meningitis  and  cerebrospinal 
syphilis.  Glucose  disappears  early  in  meningitis,  "due  to  autolysis 
controlled  by  leukocytic  ferments,  the  glucose  being  converted  into 
lactic  acid"  (Kopetsky).  The  Wassermann  test  of  the  fluid  is 
positive  in  nervous  syphilis,  as  in  the  Lange  or  colloidal  gold  test. 
Microscopic  examination  for  cells  (cytodiagnosis)  may  reveal  a 
large  number  of  polynuclear  leukocytes  (suppurative  meningitis), 
lymphocytes  (tuberculous  and  epidemic  cerebrospinal  meningitis — 
moderate  lymphocytosis  may  occur  in  superficial  tumors  and  syphilis 
of  the  brain  or  cord,  in  alcoholic  meningitis,  in  uremia),  or  erythro- 
cytes (fracture  of  the  skull  or  spine,  subdural  hemorrhage,  hemor- 
rhagic meningitis).     In  the  last  instance  the  fluid  should  be  collected 

in  two  tubes,  and  only  that  in  the  second  one  examined.     Bacterio- 

3.5 


546  MANUAL    OF   SURGERY 

logic  examination  may  discover  the  organism  responsible  for  a 
meningitis,  f q.v.) ,  for  poliomyelitis,  or  for  sleeping  sickness  (trypano- 
soma  Gambiense). 

INJURIES  OF  THE  SPINE 

Sprains  of  the  spine  are  caused  by  falls,  twists,  and  violent  shocks 
when,  as  in  a  railway  accident,  the  muscles  are  not  on  guard.  The 
pathology  is  that  of  sprains  elsewhere.  The  symptoms  are  pain, 
tenderness,  and  rigidity.  Fracture  without  displacement  and  with- 
out nervous  symptoms  might  give  identical  symptoms,  and  the 
author  has  seen  several  cases  in  which  a  correct  diagnosis  could  be 
made  only  by  an  X-ray  examination.  In  a  strain  of  the  back,  such 
as  is  produced  by  heavy  lifting,  the  lesion  is  in  the  muscles,  not  in  the 
joints.  Sprains  are  rarely  serious,  although  they  are  occasionally 
followed  by  bleeding  into  the  spinal  canal,  extension  of  the  inflam- 
mation to  the  meninges,  traumatic  neuroses,  or,  in  those  so  predis- 
posed, by  spinal  caries.  The  treatment  is  local  applications  as  in 
sprains  in  other  parts  of  the  body,  and  rest  in  bed  in  the  severer  cases. 

Concussion  of  the  spinal  cord  is  caused  by  blows  or  falls  which 
shake  or  jar  the  cord.  Theoretically  at  least,  no  anatomical  change 
is  produced.  When  minute  hemorrhages  or  like  lesions  occur,  the 
term  contusion  is  applicable.  Concussion  is  becoming  rarer  with 
improved  methods  of  investigation,  and  some  have  doubted  even 
its  existence.  The  author,  however,  has  seen  two  cases  of  gunshot 
wound,  close  to  but  not  invoh'ing  the  dorsal  cord,  in  which  there 
were  t\'pical  symptoms  of  a  total  transverse  lesion,  but  in  which 
autopsy  revealed  no  anatomical  changes  in  the  cord.  The  symptoms 
are  those  of  shock,  and  usually  a  limited,  incomplete,  and  transient 
interference  with  sensation  and  motion,  although,  as  noticed  above, 
they  may  be  those  of  a  total  lesion.  After  any  injury  to  the  cord 
the  reflexes  may  be  absent,  at  least  for  a  time.  The  prognosis  in  the 
mildest  cases  is  good,  the  symptoms  disappearing  within  a  few  hours 
or  days.  If  the  symptoms  are  severe  and  persist,  the  condition  is 
probably  one  of  contusion  or  compression  rather  than  concussion. 
Neurasthenia,  hysteria,  or  organic  cord  disease  may  follow  even 
the  sKghtest  cases.  The  treatment  is  reaction  from  shock  and  rest  in 
bed.     If  compression  is  suspected,  laminectomy  may  be  indicated. 

Traumatic  neuroses  may  occur  after  any  injury  or  severe  mental 
shock,  but  are  most  frequently  the  result  of  sprains  of  the  spine  or 
concussion  of  the  cord  due  to  railway  accidents,  hence  the  term 
''railway  spine;"  when  following  an  injury  to  the  head  the  condition 
has  been  termed  ''railway  brain."'     The  symptoms^  which  may  closely 


SPINE  547 

follow  the  accident,  or  be  delayed  for  hours  or  even  days,  are  those  of 
neurasthenia  {traumatic  neurasthenia),  hysteria  {traumatic  hysteria), 
or  hystero-neurasthenia,  and  are  identical  with  those  occurring  in 
non-traumatic  cases,  for  which  the  reader  is  referred  to  a  text-book 
on  medicine.  Other  nervous  affections,  such  as  neurotic  diabetes, 
paralysis  agitans,  chorea,  exophthalmic  goiter,  tabes,  myelitis,  and 
similar  inflammatory  and  degenerative  processes,  may  follow  acci- 
dents such  as  have  been  described  above.  The  diagnosis  of  traumatic 
neuroses  requires  great  care,  first  to  rule  out  organic  disease,  secondly 
to  detect  malingerers  who  feign  disease  in  order  to  secure  damages. 
The  prognosis  is  generally  favorable.  The  treatment  is  that  of  non- 
traumatic neurasthenia  and  hysteria. 

Compression  of  the  spinal  cord  develops  suddenly  in  fractures, 
dislocations,  foreign  bodies,  and  intramedullary  hemorrhage;  more 
slowly  in  extramedullary  hemorrhage  (within  twenty-four  or  forty- 
eight  hours),  inflammatory  exudate,  e.g.,  in  acute  spinal  meningitis 
(in  the  course  of  several  days),  and  pachymeningitis  (a  week  or 
longer) ;  and  very  gradually  in  tumors,  cysts,  aneurysms,  callus 
formation,  cicatrices,  etc.  The  symptoms  and  the  means  of  determin- 
ing the  level  of  the  lesion  have  already  been  considered  under  spinal 
localization.  The  treatment  varies  with  the  nature  and  cause  of 
compression,  and  will  be  given  when  the  individual  forms  are 
discussed. 

.  Fracture  of  the  spine  is  caused  by  direct,  or  much  more  fre- 
quently by  indirect  violence.  In  the  former  the  break  is  situated  at 
the  point  struck  and  the  arches  are  particularly  liable  to  sufifer,  a 
spicule  of  bone  often  being  driven  into  the  cord.  In  the  latter  the 
injury  is  usually  due  to  hyperflexion  of  the  spine,  such  as  occurs 
when  a  man  dives  into  shallow  water,  falls  from  a  height  on  the  feet 
or  buttocks,  or  is  doubled  up  by  the  caving  in  of  an  embankment, 
the  vertebral  column  generally  breaking  at  the  junction  of  a  freely 
movable  with  a  comparatively  fixed  portion,  i.e.,  in  the  cervico-dorsal 
(most  frequent)  or  dorso-lumbar  region.  The  bodies  of  the  vertebrae, 
with  or  without  the  arches,  are  broken,  and  the  upper  segment 
usually  displaced  forwards  (fracture-dislocation) ,  thus  contusing  or 
compressing  the  cord.  The  muscles,  ligaments,  and  membranes 
may  be  torn,  and  blood  may  collect  between  the  bone  and  the 
membranes,  or  between  the  membranes  and  the  cord. 

The  symptoms  are  (i)  shock  of  varying  degree;  (2)  local  evidences 
of  fracture,  such  as  pain,  sweUing,  tenderness,  usually  deformity 
and  possibly  crepitus;  and  (3)  interference  with  the  functions  of  the 
cord,  due  to  concussion,  contusion,  or  compression,  i.e.,  more  or  less 


548  MANUAL    OF    SURGERY 

complete  paralysis  and  anesthesia  below  the  injury,  with  decrease  or 
abolition  of  the  reflexes,  and  trophic  changes  (see  spinal  localization). 
Without  displacement,  cord  symptoms  may  be  absent,  and  in  some 
cases  the  diagnosis  can  be  made  only  by  the  X-ray.  In  seven  cases 
at  the  Jefferson  and  Pennsylvania  Hospitals  careful  X-ray  examinations 
failed  to  show  fractures  revealed  at  operation.  Paralysis  coming  on 
after  a  short  interval  may  be  due  to  edema  of  the  cord,  extramedul- 
lary  hemorrhage,  inflammatory  exudate,  or  secondary  displacement 
of  bone.  The  symptoms  of  complete  transverse  destruction  of  the 
cord  have  already  been  given.  Incomplete  destruction  may  be 
diagnosticated  when  there  is  incomplete  paralysis,  partial  anesthesia, 
and  retention  of  the  reflexes  in  the  parts  supplied  by  the  cord  below 
the  injury;  not  infrequently,  however,  the  symptoms  will  be  identical, 
sometimes  for  several  days  or  longer,  with  those  of  a  total  transverse 
lesion.  The  prognosis  in  all  cases  with  total  paralysis  and  complete 
anesthesia  is  distinctly  unfavorable,  both  regarding  life  and  return 
of  function.  The  higher  the  lesion  the  worse  the  prognosis.  Death 
occurs  immediately  from  shock  or  interference  mth  respiration  (in 
the  upper  cervical  region) ;  during  the  first  week  from  suffocation  with 
mucus  (in  the  lower  cervical  region)  or  from  meningitis;  or  after 
weeks  or  months  from  exhaustion  and  sepsis  the  result  of  extensive 
bed  sores,  cystitis,  or  pyonephrosis.  With  even  a  completely  divided 
cord,  however,  life  may  be  prolonged  for  years  if  the  injury  is  in  the 
dorsal  or  lumbar  region. 

The  treatment  is  first  reaction  from  shock.  Whether  or  not 
operation  has  been  decided  upon,  the  patient  should  be  placed  on  an 
air  or  water  bed  and  most  carefully  nursed  to  prevent  bed  sores.  The 
bladder  should  be  catheterized  every  eight  hours,  or  more  often, 
with  the  most  rigid  aseptic  precautions  to  prevent  cystitis.  Massage 
and  electricity  should  be  employed  to  maintain  the  nutrition  of  the 
paralyzed  parts.  Attempts  to  effect  reduction  by  extension  and 
pressure,  without  operative  exposure  of  the  parts,  are  too  dangerous 
to  be  recommended.  Excepting  fractures  in  the  cervical  region, 
sand  bags,  plaster  casts,  etc.,  are  seldom  required  to  immobilize  the 
parts.  There  is  no  general  agreement  as  to  the  indications  and  time 
for  operation.  Many  neurologists  and  a  few  surgeons  doubt  the 
value  of  laminectomy  in  any  case.  This  condition  of  aft"airs  is  due 
to  the  difficulty  of  differentiating  concussion  from  compression,  and 
to  the  teaching  that  the  tissues  of  the  cord  are  incapable  of  regenera- 
tion; the  latter  is  true  w^th  regard  to  the  brain,  however,  but  does 
not  deter  surgeons  from  operating  early  and  radically  in  fractures 
of  the  skull.     The  author's  views,  which  are  not  those  generally 


SPINE 


549 


adopted,  arc  as  follows:  Fractures  of  the  spine  should  be  treated  like 
fractures  of  the  skull,  i.e.,  for  (i)  disinfection;  (2)  depression,  and 
(3)  compression,  i.  All  compound  fractures  must  be  disinfected. 
2.  Obvious  depression  of  the  laminae  will  often  be  associated  with 
symptoms  of  compression,  but  even  in  the  absence  of  such  symptoms, 
the  depressed  bone  should  be  removed,  because  of  the  danger  of 
injury  to  the  cord  by  displacement  of  the  fragments  during  subsequent 
treatment,  and  because  of  the  danger  of  pressure  from  callus  on  the 
cord  or  nerve  roots  at  a  later  period.  3.  All  fractures,  whether  simple 
or  compound,  with  symptoms  of  compression  require  laminectomy 
as  soon  as  shock  has  subsided,  unless  in  the  meantime  the  symptoms 
have  distinctly  ameliorated.  The  more 
severe  the  symptoms  the  more  impera- 
tive the  operation.  It  is  true  that  at 
this  period  one  cannot  always  be  sure 
whether  the  symptoms  are  those  of  con- 
cussion, contusion,  or  compression,  but 
pure  concussion  is  rare,  and  contusion 
with  its  subsequent  edema  can  only  be 
benefited  by  the  drainage  of  operation. 
The  compressing  agent  (bone,  blood  clot, 
foreign  body)  should  be  removed  before 
the  onset  of  secondary  degeneration. 
Removal  of  the  posterior  arches  may  be  p^^  272.-Diagram  of  frac- 
all  that  is  required,  or  compression  may  ture-disiocation  of  the  'spine, 

,  .,  .       ,  111         r  showing  compression  of  the  cord 

be  caused  likewise  by  the  body  of  a  verte-  by  the  lamina  of  the  9th  dorsal 
bra  (Fig.   272),  in  which  case  reduction  I'^'^^^lt i^'^'  T'^^Ju^^lf^ n 

^      o         I    ■>  y  ^  ^  the  I oth  dorsal  vertebra  (B).  •    C. 

maybe  attempted  by  extension  and  direct  Spines  in  same  case  as  felt  from 
pressure,  or  failing  in  this,  the  projecting 

edge  of  bone  should  be  bitten  away  with  rongeur  forceps,  taking  care 
not  to  contuse  the  cord.  If  the  dura  is  distended  or  bluish  and  no 
pulsation  can  be  detected,  a  subdural  clot  exists,  and  such  should  be 
removed.  If  the  spinal  sheath  seems  empty,  the  dura  should  likewise 
be  opened  and  the  divided  cord,  for  such  will  probably  be  found, 
sutured  with  catgut  (see  also  wounds  of  the  cord).  Operation  is 
not  indicated  in  simple  fractures  without  obvious  depression  or  cord 
symptoms,  or  in  simple  fractures  with  cord  symptoms  which  are 
improving. 

Dislocations  of  the  vertebrae  without  fracture  are  extremely 
rare  and  confined  almost  exclusively  to  the  cervical  region,  usually 
the  lower  half.  The  upper  vertebra  is  called  the  dislocated  one 
contrary  to  the  custom  when  speaking  of  dislocations  elsewhere. 


55° 


MANUAL    OF    SURGERY 


The  usual  cause  is  hyperflexion,  both  articular  processes  of  the  upper 
vertebra  passing  in  front  of  those  of  the  lower  vertebra,  i.e.,  a  com- 
plete bilateral  anterior  dislocation  (Fig.  273).  Bilateral  posterior 
dislocation  ma}'  be  caused  by  hyperextension,  unilateral  dislocation 
by  forcible  approximation  of  the  head  and  shoulder  combined  with 
rotation.  Incomplete  dislocation  also  may  occur  (Fig.  274).  The 
ligaments  and  intervertebral  discs  are  torn,  and  in  complete  bilateral 
cases  the  cord  is  almost  always  compressed,  usually  causing,  in  the 
upper  cervical  region,  immediate  death.  In  many  incomplete  or 
unilateral  cases,  the  cord  may  escape  pressure  by  bone,  although  it 
may  still  be  compressed  by  blood  clot,  and  the  nerve  roots  may  be 
stretched  or  torn,  causing  neuralgia,  etc.  In  forward  dislocations 
the  head  is  displaced  forwards  and  bent  towards  the  chest.  In 
backward  dislocations  the  head  is  displaced  backwards  and  the  face 
turned  upwards.     In  unilateral  dislocations  the  head  is  bent  towards 


Fig.  273. — Complete  dislocation. 
(Marion.) 


Fig.  274. 


-Incomplete  dislocation. 
(Marion.) 


the  sound  shoulder.  The  deformity  may  be  felt  externally  or  through 
the  pharynx,  and  demonstrated  with  the  X-ray;  in  any  case  there  is 
likely  to  be  difficulty  in  swallowing. 

The  treatment  of  unilateral  and  incomplete  dislocations  is 
reduction,  under  an  anesthetic,  by  traction  and  approximation  of  the 
head  towards  the  sound  shoulder  to  unlock  the  processes,  then  rota- 
tion of  the  head,  the  ear  on  the  sound  side  moving  forwards.  In 
long  standing  cases  reduction  cannot  be  effected,  but  operation  may 
be  undertaken  to  reheve  pressure  on  the  spinal  nerves.  Bilateral 
dislocations  may  be  reduced  by  bending  the  head  towards  the  right 
shoulder  and  rotating  the  head  (the  right  ear  being  carried  forward) , 
thus  converting  the  dislocation  into  a  unilateral  one,  which  may  be 
reduced  by  reversing  the  movements  just  described.  These  manipu- 
lations are  so  dangerous, that  it  is  probably  best  to  relieve  pressure 
by  at  once  removing  the  laminae  of  the  dislocated  vertebra,  and  then 
reducing  the  bones  under  the  guidance  of  the  finger  and  eye.  If 
sufficient  traction  cannot  be  exerted  to  unlock  the  processes,  as 
little  as  possible  of  the  upper  margin  of  the  upper  articular  processes 
of   the   lower   vertebra   should   be   removed  to  permit  reduction. 


SPINE  551 

Removal  of  the  whole  process  would,  of  course,  permit  recurrence 
which  however,  might  be  prevented  by  fixing  the  spinous  processes 
with  a  transplant  from  the  spine  of  the  scapula.  The  dura  may  be 
opened  to  remove  coagulated  blood. 

Wounds  of  the  spinal  cord  are  usually  the  result  of  stabs  or  gun- 
shot injuries.  There  may  be  complete  paralysis  below,  or  if  half  of 
the  cord  is  divided,  loss  of  motion  on  the  same  side  and  anesthesia  on 
the  opposite  side,  or  again  the  injury  may  be  limited  to  the  nerve 
roots.  It  is  generally  taught  that  regeneration  of  the  cord  never  occurs. 
The  treatment  is  laminectomy,  removal  of  foreign  bodies  and  com- 
minuted bone,  and  suture  of  the  wound  of  the  cord  and  of  the  severed 
spinal  nerves  with  catgut.  The  dura  should  be  closed  whenever 
possible.  Probes  should  never  be  employed  to  explored  the  wound. 
In  the  cervical  region  it  may  be  necessary  to  tie  the  vertebral  artery. 

Intraspinal  hemorrhage  may  be  extradural,  subdural,  or  intramed- 
ullary. It  is  usually  the  result  of  injury,  but  may  be  due  to  other 
causes,  e.g.,  acute  infectious  fevers,  convulsions,  rupture  of  aneu- 
rysms, etc. 

In  extra-  and  subdural  hemorrhage  {heviatorrhachis)  the  symp- 
toms are  pain  in  the  back  and  irritation  of  the  nerve  roots  (pain 
hyperesthesia,  and  spasms  in  the  parts  supplied  by  the  affected 
nerves),  followed  by  symptoms  of  compression,  the  paralysis  and 
anesthesia  coming  on  suddenly,  or  perhaps  slowly  from  below  up- 
wards as  the  blood  increases  in  amount.  Complete  recovery  may 
occur  in  traumatic  cases.  The  treatment,  excepting  the  milder  forms, 
is,  in  the  early  stages  when  the  blood  is  still  fluid,  spinal  puncture, 
and  at  a  later  period  laminectomy  and  removal  of  the  clot. 

Intramedullary  hemorrhage  {hem atomy elia)  is  most  frequent  in 
the  lower  cervical  region.  The  symptoms  are  sudden  paralysis 
and  anesthesia  of  the  parts  below,  and  intense  pain  in  the  back. 
The  lesion  may  be  unilateral  (paralysis  on  one  side,  anesthesia  on  the 
other),  or  if  the  bleeding  is  slight,  signs  of  irritation  may  be  present. 
but  are  not  so  common  as  in  extrameduUary  hemorrhage.  The  usual 
treatment  is  that  of  concussion. 

DISEASES   OF   THE   SPINE 

Spina  bifida  (jachischisis) ,  or  failure  of  the  spinal  laminae  to  unite, 
is  present  in  about  one  in  every  1,000  children  born.  Sometimes 
there  is  a  small  congenital  gap  in  the  spine,  the  cord  and  membranes 
remaining  in  the  canal  {spina  bifida  occulta) ;  the  skin  is  frequently 
indented  over  this  defect  and  the  dimple  filled  with  hair.     These 


552 


MANUAL    OF    SURGERY 


cases  need  no  treatment  unless  there  are  symptoms  of  pressure  on 
the  cord,  when  the  removal  of  such  compression,  which  may  be  due 
to  hypertrophy  of  the  skin  and  subjacent  soft  parts,  would  be  indicat- 
ed. In  2  per  cent,  of  the  cases  the  cleft  is  wide,  the  skin  is  absent, 
and  the  cord  protrudes  through  the  opening,  its  central  canal  com- 
municating with  the  surface  of  the  body  {myelocele) .  This  condition 
is  not  compatible  with  existence.  In  lo  per  cent,  the  membranes 
alone  escape  through  the  opening  {meningocele),  but  in  the  vast 
majority  (about  75  per  cent.)  there  is  also  a  portion  of  the  cord  in  the 
protuberance  {meningomyelocele),  and  very  rarely  the  tumor  is  the 
result  of  a  dilatation  of  the  central  canal  of  the  cord  {syringomyelocele) . 
The  last  variety  is  often  situated  laterally.  More  than  one  vertebra 
is  usually  fissured,  and  cases  have  been  reported  in  which  all  the 
vertebrae  were  involved.  Rarely  the  body  of  the 
vertebra  is  implicated  {anterior  spina  bifida).  One- 
half  of  all  cases  occur  in  the  lumbar  region,  and 
more  than  one-third  in  the  lumbosacral  or  sacral 
portion  of  the  spine. 

Diagnosis. — The  swelling  is  congenital,  almost 
central,  and  partly  reducible,  pressure  causing  the 
fontanelles  to  bulge  and  some  times  producing  con- 
vulsions or  other  nervous  symptoms.  Palpation 
and  the  X-ray  reveal  the  cleft,  and  there  is  bulging 
on  crying  or  coughing.  Translucency  may  be  de- 
tected, with  the  cord  or  nerves  represented  as 
shadows.  There  may  be  other  developmental  de- 
PiG.  275.— Spina  fects,  such  as  hare-lip  and  talipes  (Fig.  275),  and  as 

bifida  and  club  foot,    ^i  ^^        c  •  i  ^•.•  r    .^ 

(Kirmisson.)  the  rcsult  ot  comprcssion  or  abnormalities  of  the 

nervous  elements,  anesthesia,  paralysis  or  trophic 
changes  may  be  found  below  the  cloven  spine. 

The  prognosis  is  bad,  although  spontaneous  recovery  may  occur 
in  rare  instances  when  the  opening  is  small  and  the  skin  thick  and 
healthy.  Death  is  due  to  marasmus,  to  the  sequelae  of  paralyses,  or 
to  meningitis  following  rupture  or  inflammation  of  the  sac. 

The  treatment,  if  operation  is  not  decided  on,  is  protection  of  the 
sac  by  collodion  or  a  suitable  cap,  in  order  to  prevent  rupture. 
Morton's  fluid  (iodin  gr.  10,  potassium  iodid  gr.  30,  glycerin  i  oz.) 
may  be  injected  in  the  dose  of  2  dr.,  repeated  in  ten  days  if  necessary 
care  being  taken  during  the  injection  to  obliterate  the  neck  of  the  sac 
as  much  as  possible  by  compression.  This  plan  has  so  often  been 
followed  by  sloughing  and  rupture  of  the  sac,  by  convulsions  and 
meningitis,  and  by  paralysis  and  hydrocephalus  (mortality  40  per 


SPINE 


553 


cent.),  that  most  surgeons  j)refer  excision  (mortality  2>,  percent.). 
The  lumbar  region  in  infants  is  so  difficult  to  keep  clean  that  opera- 
tion should  be  postponed  as  long  as  possible.  If  the  skin  is  thin,  or 
threatens  to  ulcerate,  or  if  the  tumor  is  enlarging,  operation  becomes 
imperative.  An  elliptical  incision  is  made  about  the  tumor,  and  the 
sac  opened  laterally  by  a  small  transverse  cut,  in  order  to  avoid  the 
cord,  which  may  be  adherent  in  the  middle  line,  and  the  nerves  which 
run  at  right  angles  to  it.  If  no  nervous  tissues  are  present,  the  sac 
is  removed  and  the  opening  sutured  with  catgut.  If  nervous  struc- 
tures are  present,  they  are  separated  from  the  sac;  if  intimately  ad- 
herent, that  portion  of  the  sac  in  which  they  are  incorporated  may 
be  reduced  with  them  into  the  spinal  canal.  The  muscles  on  each 
side  are  then  loosened,  sutured  together,  and  the  skin  closed.  The 
bony  defect  has  been  closed  bv  drawing  the  remnants  of  the  laminae,  if 


Fit..   276. —  Sacrococcygeal  teratoma. 

present,  over  the  gap;  by  swinging  a  flap  of  bone,  attached  by  its  peri- 
osteum, from  the  outer  table  of  the  ilium;  by  a  bone  graft,  such  as 
the  scapula  of  the  rabbit;  and  by  foreign  substances,  such  as  a  plate 
of  celluloid;  procedures  of  this  character  are  rarely  necessary. 
Recurrences  sometimes  occur  and  hydrocephalus  may  follow. 

Congenital  sacrococcygeal  tumors  occur  on  the  dorsal  or  ventral 
surface.  Lipomata  may  communicate  with  the  interior  of  the  spinal 
canal,  dermoids  with  the  rectum,  bladder, , or  spinal  meninges.  Cystic 
tumors  containing  a  myxomatous  material  and  developing  between 
the  rectum  and  sacrum  originate  in  the  remains  of  the  postanal  gut, 
or  neurenteric  canal  (the  canal  which  connects  the  neural  and  enteric 
tracts  in  early  fetal  life).  Teratomata  (Fig.  276),  sarcomata,  and 
spina  bifida  constitute  the  remaining  congenital  tumors  in  this  region. 
The  treatment  is  removal;  it  may  be  necessary  to  excise  a  portion  of 
the  sacrum  or  split  the  posterior  wall  of  the  rectum. 


554  MANUAL    OF    SURGERY 

Sacrococcygeal  fistulas  or  Pilonidal  sinus  are  the  result  of  imper- 
fect coalescence  of  the  skin,  or  persistence  of  the  postanal  gut.  The 
simplest  form  is  the  postanal  dimple.  Others  may  communicate 
with  the  rectum  or  spinal  canal.  The  treatment  is  excision  unless 
the  condition  gives  no  trouble. 

Spinal  curvatures  include  scoliosis,  kyphosis,  and  lordosis. 

Scoliosis,  or  lateral  curvature,  rarely  involves  the  spine  in  one 
curve  {total  scioliosis) ;  as  a  rule  there  are  two  or  more  lateral  curves 
with  their  convexities  in  opposite  directions  (Fig.  277).  Lateral 
deformities  of  the  spine  due  to  caries,  fracture,  tumors,  etc.,  are  not 
placed  under  this  heading.  The  causes  are  rickets;  asymmetry,  the 
result  of  shortness  of  one  leg,  empyema,  torticollis,  etc,;  faulty  post- 
ures, the  result  of  habit  (e.g.,  standing  on  one  leg),  occupation  (e.g., 
constantly  working  a  lever  with  one  hand  or  foot),  or  disease  (e.g., 
sacroiliac  disease) ;  and  central  nervous  diseases,  producing  unilateral 
atrophy  or  spasms  of  the  muscles.  The  most  common  form  is  the 
scoliosis  of  adolescence,  due  to  relaxed  muscles  and  hgaments  which 
do  not  develop  as  rapidly  as  the  spine.  One  of  the  causes  men- 
tioned above  may  be  a  contributing  factor.  The  patients  are  usually 
anemic  girls,  easily  fatigued,  and  frequently  assuming  attitudes  of 
rest,  e.g.,  standing  with  the  weight  resting  on  one  leg  or  lounging  in 
a  faulty  position. 

Symptoms  and  Pathological  Anatomy. — In  the  usual  variety  the 
lumbar  spine  becomes  convex  towards  the  left,  and  later  a  compen- 
satory dorsal  curve  with  the  convexity  to  the  right  develops;  there 
may  or  may  not  be  an  associated  kyphosis.  The  vertebral  column 
not  only  deviates  laterally,  but  is  twisted  in  a  spiral  direction,  the 
spines  rotating  towards  the  concavity,  so  that  they  do  not  give,  an 
accurate  indication  of  the  degree  of  curvature.  The  ribs  on  the  right 
side  are  separated,  more  horizontal,  and  bent  at  their  angles;  the 
shoulder  is  raised,  the  scapula  more  prominent,  and  the  front  of  the 
chest  flattened.  On  the  left  side  the  ribs  are  crowded  together  and 
their  angles  are  more  obtuse,  so  that  the  shoulder  is  lower,  the  scap- 
ula less  prominent,  and  the  chest  projects  anteriorly.  The  sternum 
moves  towards  the  concavity  and  faces  the  convexity.  In  the  worst 
cases  the  thoracic  and  abdominal  viscera  are  displaced.  The  left 
hip  projects  and  the  waist  on  the  right  side  is  more  marked.  In  the 
initial  stages  the  deformity  disappears  on  bending  forward,  or  on 
hanging  from  a  bar,  but  in  the  fixed  stage  when  the  bones  have  be- 
come altered  in  shape  this  is  im.possible.  Malaise,  backache,  inter- 
costal neuralgia,  dyspnea,  and  dyspepsia  may  annoy  the  patient. 
The  prognosis  is  good  if  the  cause  can  be  removed  and  the  spine 


SPINE 


555 


Pig.   277. — Scoliosis.     (Philadelphia  College  of  Physicians.) 


556  MANUAL    OF    SURGERY 

straightened  by  extension.  In  the  later  stages  improvement  may  be 
obtained  or  at  least  the  progress  of  deformity  interrupted. 

The  treatment  is  removal  of  the  cause  when  such  is  possible,  the 
correction  of  vicious  attitudes,  massage  and  electricity  to  the  weak- 
ened muscles,  and  gymnastic  exercises,  such  as  swinging  from  a  bar, 
riding  a  bicycle  with  an  inclined  seat,  balancing  a  light  weight  on  the 
head,  placing  the  hands  together  above  the  head  and  bending  for- 
wards, etc.  The  general  health  should  receive  attention  and  the 
patient  should  rest  in  the  recumbent  posture  daily.  Braces  and 
supports  tend  to  weaken  the  muscles,  and  are  employed  only  when 
deformity  is  advancing  despite  other  treatment.  In  suitable  cases 
Abbott's  method  seems  to  offer  the  best  prospects  for  complete  re- 
covery. The  patient  lies  with  the  back  flexed  in  a  canvas  hammock. 
Straps  are  passed  around  the  body  in  various  directions,  and  fastened 
to  a  frame  of  gas  pipe,  the  bars  of  which  are  rotated,  thus  winding 
up  the  straps,  until  the  deformity  is  corrected  as  far  as  possible.  A 
plaster-of-Paris  jacket,  with  pads  arranged  to  maintain  the  correc- 
tion, is  then  applied.  After  the  plaster  has  hardened  windows  are 
cut  in  the  jacket  posterolaterally  over  the  site  of  the  previous  con- 
cavity of  the  spine,  and  anterolaterally  over  the  site  of  the  previous 
convexity.  Through  these  windows  felt  pads  are  introduced  to 
gradually  increase  the  amount  of  correction.  The  casts  are  changed 
every  four  to  six  months,  until  overcorrection  is  obtained.  The 
patient  then  wears  a  celluloid  jacket,  except  when  taking  exercises 
to  strengthen  the  muscles,  until  there  is  no  longer  any  tendency 
toward  recurrence  of  the  deformity. 

Kyphosis,  or  dorsal  convexity  of  the  spine,  may  involve  the  whole 
column,  as  is  physiological  in  infants,  but  is  usually  confined  to  the 
dorsal  region  and  may  or  may  not  be  associated  with  a  compensatory 
lumbar  lordosis.  The  causes  are  rickets;  faulty  postures,  the  result 
of  habit  (as  in  piano  playing),  occupation  (cobblers,  tailors,  etc.) 
or  disease  (myopia,  dyspnea,  asthma,  emphysema  and  chronic 
abdominal  disease) ;  afections  of  the  spine,  such  as  tuberculosis, 
syphilis,  malignant  growths,  aneurysmal  erosion,  osteoarthritis, 
ostitis  deformans,  osteomalacia,  hypertrophic  pulmonary  osteoarth- 
ropathy, and  acromegaly; /mc/z/r^5;  and  senile  atrophy.  The  round 
shoulders  of  adolescence  occurs  in  the  same  type  of  patients  as  the 
scoliosis  of  adolescence. 

The  treatment  varies  with  the  cause;  many  of  the  forms  mention- 
ed above  cannot  be  remedied.  In  adolescence  round  shoulders  may 
require  the  correction  of  myopia  or  the  removal  of  adenoids.  Vicious 
postures   should   be   corrected,   and   the   muscles   strengthened  by 


SPINE  557 

massage,  electricity,  and  exercises;  rest  should  be  taken  on  a  hard 
mattress,  with  a  pillow  beneatii  the  deformit)'.  If  the  deformity  is 
progressive,  a  brace  may  be  required. 

Lordosis,  or  anterior  curvature  of  the  lumbar  spine,  is  compensa- 
tory in  kyphosis,  large  abdominal  tumors,  pregnancy,  etc.  The 
most  common  cause  is  fixation  of  the  hip  in  flexion,  e.g.,  in  congenital 
or  unreduced  dislocations  and  in  hip  disease  or  ankylosis.  It  occurs 
also  in  rickets,  caries  of  the  posterior  part  of  the  vertebral  bodies, 
progressive  muscular  atrophy,  pseudohypertrophic  paralysis,  and 
spondylolisthesis.  The  treatment  is  removal  of  the  cause  when  such 
is  possible. 

Spondylolisthesis  is  a  rare  condition  confined  almost  exclusively 
to  the  lumbosacral  joint.  As  the  result  of  imperfect  development  or 
fracture  of  the  articular  processes,  the  spinal  column  slips  downward 
and  forward  from  the  sacrum,  thus  causing  marked  lordosis  and 
shortening  of  stature.  The  treatment  is  extension  in  the  recumbent 
posture.  If  the  patient  sits  up  or  w^alks,  a  brace  will  be  needed  to 
convey  the  weight  of  the  body  to  the  pelvis.  Ryerson  treated  one 
patient  successfully  by  splinting  the  spine  with  a  bone  graft. 

Spondylitis  deformans  is  osteoarthritis  of  the  spine  w-hich  results 
in  locking  of  the  vertebrae  by  osteophytes.  There  .are  pain  and  ten- 
derness, with  kyphosis  and  perhaps  pressure  on  the  nerve  roots. 
The  treatment  is  that  of  osteoarthritis  elsew^here.  Braces  are  occa- 
sionally required  to  prevent  increase  of  deformity. 

T3rphoid  spine  is  a  term  applied  to  a  periostitis  or  ostitis  following 
t>^hoid  fever.  There  are  pain,  tenderness,  and  weakness  of  the 
spine,  with  muscular  rigidity.  Suppuration  rarely  occurs.  The 
treatment  is  a  plaster  cast  or  leather  jacket,  and  later  massage  and 
electricity. 

Acute  osteomyelitis  of  the  vertebrae  is  uncommon  and  is  due  to  the 
same  causes  as  osteomyelitis  elsew^here.  When  the  arches  are  in- 
volved the  condition  is  easily  recognized,  but  when  the  bodies  are 
aft'ected  the  diagnosis  is  often  difficult,  the  condition  being  mistaken 
for  typhoid  fever,  peritonitis,  etc.  The  infection  may  spread  to  the 
meninges,  the  symptoms  then  being  those  of  meningitis.  The  symp- 
toms are  acute  pain  and  tenderness,  rigidity  of  the  spinal  muscles, 
and  the  constitutional  symptoms  of  sepsis.  The  abscess  may  appear 
posteriorly  or  anteriorly  (retropharyngeal,  mediastinal,  lumbar,  or 
pelvic).  The  treatment  is  that  of  osteomyelitis  elsewhere,  viz.,  in- 
cision and  drainage,  and  at  a  later  period  removal  of  the  sequestrum. 

Tuberculosis  of  the  spine  (Pottos  disease,  angular  curvature, 
spondylitis)  may  occur  at  any  period  of  life,  but  is  most  frequent 


558 


MANUAL   OF    SURGERY 


between  the  sixth  and  tenth  year.  Heredity,  impaired  health,  poor 
hygienic  surroundings,  and  injuries,  often  shght  in  nature,  provide  a 
favorable  soil  for  the  tubercle  bacillus.  The  disease  may  occur  in 
any  portion  of  the  spine,  but  is  most  frequent  in  the  lower  dorsal 
region. 

The  pathology  is  that  of  tuberculous  bone  disease  elsewhere. 
The  starting  point  is  usually  on  the  anterior  surface  of  the  body  just 
beneath  the  periosteum,  or  at  the  upper  or  lower  epiphyseal  Hne;  the 
posterior  arches  are  rarely  involved  primarily.  The  cancellous  bone 
of  the  body  is  gradually  destroyed,  and  the  disease  spreads  to  neigh- 
boring vertebrae  beneath  the  anterior  common  ligament,  or  by  disin- 


FiG.   278. — Dorsolumbar  Pott" s  disease,  with  section  of  vertebrae  showing  absorption 

of  bodies.      (Young.) 

tegrating  the  intervertebral  cartilages.  Caseous  changes  occur, 
and  pus  forms,  and  burrows  in  the  direction  of  least  resistance. 
Caries  without  suppuration  {caries  sicca)  and  caries  with  the  forma- 
tion of  sequestra  {caries  necrotica)  occasionally  occur.  Owing  to  the 
destruction  of  the  bodies  of  the  vertebrae,  the  spine  bends  and  a 
posterior  angular  deformity  is  produced  (Fig.  2  78) .  The  spinal  cord 
is  occasionally  involved.  Cure  is  effected  by  the  formation  of  new 
bone,  ankylosis  of  the  vertebrcC,  and  the  organization  or  calcification 
of  the  surrounding  inflammatory  tissue. 

The  local  symptoms  are  pain,  rigidity,  deformity,  abscess,  paraly- 
sis.    Pain  is  rarely  severe,  indeed  may  be  absent.     It  is  increased  by 


SPINE  559 

local  pressure,  movements,  and  jarring  of  the  spine.  \\  hen  the  nerve 
roots  are  irritated  the  pain  is  referred  to  the  area  supplied  by  these 
nerves.  Rigidity  in  the  early  stages  is  due  to  muscular  spasm,  which 
is  nature's  effort  to  protect  the  diseased  part.  In  the  convalescing 
stage  immobility  of  the  spine  is  due  to  ankylosis.  Movements  of  the 
spine  are  instinctively  resisted.  The  patient  walks  like  a  marionette, 
refuses  to  jump,  stoops  by  bending  the  knees  and  hips  and  not  the 
back,  turns  around  by  moving  the  whole  body  as  a  unit  instead  of 
rotating  the  spine  (particularly  in  cervical  caries),  and  when  sitting 
takes  the  weight  of  the  upper  part  of  the  trunk  from  the  diseased 
vertebrae  (lower  dorsal  or  lumbar  caries)  by  grasping  the  arms  of 
the  chair.  The  hardening  of  the  muscles  is  easily  appreciable  to 
the  fingers.  Deformity  varies  in  nature  and  degree  according  to  the 
location  and  extent  of  the  disease.  In  the  early  stages  a  slight 
lordosis  in  the  cervical  or  lumbar  region  may  be  caused  by  muscular 
spasm,  very  rarely  by  caries  of  the  posterior  part  of  the  vertebral 
body.  Disease  of  the  arches  does  not  produce  deformity.  When  the 
disease  affects  one  side  more  than  the  other  and  lateral  curvature 
occurs,  the  torsion  of  the  vertebrae  is  in  the  opposite  direction  to  that 
of  scoliosis,  i.e.,  the  bodies  occupy  the  concave  side  of  the  curve. 
Posterior  angular  deformity  is  the  typical  one;  the  more  vertebrae 
involved  the  more  obtuse  the  angle.  In  the  cervical  and  lumbar 
regions  the  spine  necessarily  becomes  straight  before  posterior  de- 
formity can  occur;  in  the  former  situation  it  is  rarely  marked.  Com- 
pensatory curves  form  in  the  remaining  parts  of  the  spine,  and  when 
the  dorsal  vertebrae  are  badly  deformed  secondary  changes  in  the 
shape  of  the  thorax  occur.  Abscesses  occur  in  the  later  stages,  and 
owing  to  their  deep  origin  usually  attain  a  large  size  and  travel  a  long 
distance  before  being  recognized.  In  the  cervical  region  the  pus 
collects  behind  the  posterior  pharyngeal  wall  (chronic  retropharyngeal 
abscess,  see  pharynx).  In  the  upper  dorsal  region  the  abscess  usually 
perforates  the  intercostal  structures  and  appears  posteriorly  (dorsal 
abscess) ;  rarely  it  comes  to  the  surface  at  the  base  of  the  neck.  In 
the  lower  dorsal  or  the  lumbar  region  the  pus  passes  backwards 
(lumbar  abscess),  or  enters  the  psoas  sheath  (psoas  abscess)  and 
gravitates  downwards,  either  forming  a  large  swelling  in  the  iliac 
region  or  pointing  below  Poupart's  ligament,  usually  external  to  the 
femoral  vessels.  A  psoas  abscess  may,  however,  come  to  the  surface 
on  the  inner  side  of  the  vessels,  on  the  inner  side  of  the  thigh,  or  even 
as  low  as  the  heel;  occasionally  it  bursts  into  the  rectum,  bladder, 
vagina,  or  on  the  perineum.  Paralysis  is  not  frequent  (about  7  per 
cent.)  and  occurs  only  in  the  later  stages.     It  is  rarely  sudden  in 


56o 


MANUAL    OF    SURGERY 


onset,  and  is  then  probably  due  to  displacement  of  bone.  As  a  rule 
it  appears  slowly  as  the  result  of  compression  of  the  cord  by  tuber- 
culous masses  or  pus,  or  most  commonly  pachymeningitis.  Sensa- 
tion is  affected  later.     The  constitutional  symptoms  are   those  of 

tuberculosis  elsewhere. 

The  diagnosis  may  be  difhcult  before  the 
onset  of  deformity.  Localized  tenderness 
and  rigidity  are  the  most  important  symp- 
toms in  this  stage.  The  reflected  pains  may 
be  mistaken  for  pleurisy,  abdominal  disease, 
neuralgia,  rheumatism,  etc.  Angular  de- 
formity may  be  caused  also  by  syphilis, 
malignant  growths,  and  aneurysmal 
erosions.  In  kyphosis  due  to  other  causes, 
the  deformity  is  usually  a  long  curve  rather 
than  a  limited  angular  projection,  and 
rigidity  is  generally  absent.  Flexion  of  the 
hip  due  to  psoas  abscess  should  not  be  mis- 
taken for  hip  joint  disease,  and  it  should  be 
recalled  that  psoas  abscess  may  be  due  to 
other  causes  than  tuberculosis,  as  may  also 
abscesses  in  the  other  regions  indicated 
above.  The  osseous  lesion  can  almost 
is  a  \ever%ith^its  iuicrum  always  be  demonstrated  with  the  X-ray; 
point  at  small  F     The  arrow  the  tubcrcuHn  test  is  Occasionally  of  service. 

on  the  vertebral  bodies  at  2,  2, 

indicates  lines  of  force  from  The  pTOgnosis  is  good  in  children  who 
ruSspt3;.:?:Ce"cS  ="-e  efficiently  treated  from  the  beginning. 
crushing  of  vertebral  bodies  The  higher  the  discase,  the  more  vertebrae 

and  progress  of  deformity  by    .  ^-       ^      ^1 

the    approximation    of    the  mvolved,  and  the  older   the  patient,   the 

anterior  lever  arms   which  is    ^^.^^^^  ^^^  prOgnOsis.       AbsCCSSCS    which  be- 

associated  with  an  equal  sepa-  ^      ° 

ration  of  the  spinous  processes  come    infected    with    pyogeuic    organisms 

or    the    posterior  lever  arms;  i        .,  •     r  i  j^       ^     •  ^    •  ^ 

this  is  prevented  by  a  pull  causc  hcctic  fcvcr  and  cveutuate  m  amyloid 
lengthwise  on  the  graft  as  in-  discascunless  the  iufcction  cau  be  controlled. 

dicated  by  the   small   arrows 

situated  at  each  spinous  proc-  Paralysis  is  a  gravc  Complication,  but  with 
Sl;dJection''offo''rc?Sundlr  Suitable  treatment  may  entirely  disappear, 
a  great  mechanical   ad-  Death  is  usually  the  rcsult  of  cxhaustion, 

vantage.      (Albee.)  •        ^    i  i       •        1  i  •  i 

sepsis,  tuberculosis  elsewhere,  involvement 
of  the  cord  or  meninges,  or  an  intercurrent  malady.  Sudden  death 
from  dislocation  may  occur  in  disease  of  the  atlas  or  axis. 

The  treatment  is  local  and  constitutional.  For  the  latter  see 
tuberculosis.  The  local  treatment  is  (i)  rest,  (2)  correction  of  de- 
formity, (3)  evacuation  of  abscesses  and  possibly  removal  of  diseased 


SPINE 


;6i 


bone,  and  (4)  the  care  of  i)aralysis  if  il  should  occur.  Local  applica- 
tions are  useless,  and  blisters  and  the  actual  cautery  may  be  harmful 
in  predisposing  to  bed  sores,  i .  Rest  is  best  obtained  by  the  recum- 
bent posture  and  the  application  of  extension.  In  cervical  caries 
extension  is  applied  to  the  head  only  (Fig.  280),  the  head  of  the  bed 
being  slightly  elevated,  and  sand  bags  being  used  to  prevent  lateral 
motions.  In  the  lower  dorsal  or  lumbar  region  extension  should  be 
applied  also  to  the  legs.  Restless  children  may  be  fastened  to  a  Brad- 
ford frame  in  which  an  opening  has  been  provided  for  the  discharges 
from  the  bowels.  After  a  number  of  months  when  the  pain  and  acute 
symptoms  have  subsided,  or  even  before  in  adults  or  in  children  who 
do  not  stand  bed  treatment  well,  a  plaster  cast  or  a  leather  brace  should 
be  apphed  and  the  patient  allowed  to  walk  about.  Sayre's  plaster 
jacket  is  applied  as  follows:  An  armless  undershirt,  of  wool  or  stock- 


Fig.   280. — Head_extension^for  Pott's  disease.      (Young.) 


ingette  reaching  below  the  iliac  crests,  is  put  on  the  patient,  who  is  sus- 
pended from  a  tripod  (Fig.  281)  with  the  toes  just  reaching  the  ground; 
instead  of  using  the  axillary  straps  the  patient  may  grasp  the  cross 
bar  above.  In  some  cases  the  cast  should  be  applied  in  the  recum- 
bent posture  while  extension  is  being  made.  A  folded  towel  is  placed 
over  the  epigastrium,  and  this  ''dinner  pad"  is  withdrawn  after  the 
plaster  has  set;  padding  is  placed  also  over  the  posterior  deformity, 
the  iliac  crests,  and  the  breasts.  Plaster  bandages  are  now  applied 
about  the  trunk  from  the  axillae  to  below  the  iliac  crests.  In  disea;se 
above  the  middorsal  region  it  will  be  necessary  to  apply  a  jury  mast 
(Fig.  282),  or  to  include  the  neck  in  the  plaster  bandage,  so  as  to  take 
the  weight  of  the  head  from  the  body.  The  cast  may  be  split  down 
the  front  and  provided  with  hooks  for  lacing,  so  that  it  may  be  re- 
moved and  reapplied  from  time  to  time,  or  a  new  cast  may  be  ap- 
plied every  two  or  three  months.     The  cast  or  a  suitable  leather  or 


562 


MANUAL    OF    SURGERY 


felt  jacket  should  be  worn  for  at  least  six  months  after  the  patient 
is  apparently  cured.  In  order  to  secure  ankylosis,  the  spinous 
processes  of  the  vertebrae  may  be  split  longitudinally  and  a  segment 
of  the  crest  of  the  tibia  (Albee),  or  of  the  vertebral  border  of  the 
scapula  (Ombredanne)  implanted  into  the  osseous  wound. 

2.  Deformity  when  recent  may  be  gradually  corrected  by  exten- 
sion, and  gentle  pressure  over  the  gibbosity,  either  by  means  of  a  pad 
left  in  place  or  by  daily  pressure  with  the  hand.  In  old  cases  after 
ankylosis  has  occurred,  removal  of  the  spinous  processes  may  be 
indicated.  Forcible  correction  at  one  sitting,  first  proposed  by 
Chipault,  who  also  wires  the  spinous  processes  together  to  maintain 
the  reduction,  is  often  called  Calot's  method  because  of  the  enthusi- 


FiG.  281. — Sayre's  tripod. 


Fig.   282. — Sayre's  jury  mast. 


asm  with  which  he  has  advocated  it.     Most  surgeons  consider  the 
method  dangerous. 

3.  Abscesses  should  be  evacuated  when  detected.  The  general 
principles  of  the  treatment  of  chronic  abscess  have  been  considered 
in  chap,  vii,  and  the  treatment  of  retropharyngeal  abscess  will  be 
described  under  diseases  of  the  pharynx.  In  abscesses  due  to  disease 
of  the  posterior  arches,  a  free  incision  should  be  made,  the  diseased 
bone  removed,  and  the  cavity  disinfected  and  packed  with  iodoform 
gauze.  Dorsal,  lumbar,  and  psoas  abscesses  should  be  incised  at  the 
point  where  they  are  nearest  the  surface,  the  pyogenic  membrane 
and  cheesy  masses  removed  by  curetting  with  a  piece  of  gauze  on  a 
long  pair  of  forceps,  the  cavity  irrigated  with  salt  solution  and  in- 


SPINE  563 

jected  witli  iodoform  emulsion,  and  the  wound  closed  with  sutures. 
Some  surgeons  prefer  to  tap  with  a  trocar  and  cannula,  but  irrigation 
is  unsatisfactory  through  a  cannula  and  removal  of  the  debris  is 
impossible.  These  operations  may  have  to  be  repeated.  If  diseased 
bone  is  found  it  should  be  removed.  Treves^  operation  may  be  per- 
formed in  disease  of  the  twelfth  dorsal  or  any  of  the  lumbar  vertebrae. 
An  incision  is  made  along  the  outer  edge  of  the  erector  spinae  from 
the  last  rib  to  the  crest  of  the  ilium,  and  the  tissues  divided  until  the 
quadratus  lumborum  is  exposed,  which  with  the  underlying  fascia 
is  cut  transversely  to  avoid  the  lumbar  arteries.  The  abscess  is 
opened,  irrigated,  the  pyogenic  membrane  excised,  diseased  bone 
removed  with  forceps  or  chisel,  and  the  wound  closed  with  sutures. 
If  pyogenic  infection  is  present,  the  wound  should  be  left  open, 
sterilized  with  chemical  antiseptics  and  then  closed  according  to  the 
technic  of  secondary  suture.  Similar  operations  have  been  per- 
formed in  the  cervical  and,  after  resection  of  the  ribs,  in  the  dorsal 
regions. 

4.  Paralysis  is  treated  by  extension  and  gentle  pressure  to  correct 
"the  deformity,  care  being  taken  to  preserve  nutrition,  prevent  bed 
sores,  cystitis,  etc.,  as  indicated  under  fracture  of  the  spine.  As 
compression  of  the  cord  is  usually  caused  by  pachymeningitis,  and  as 
recovery  frequently  follows  this  treatment,  laminectomy  is  employed 
only  when  the  symptoms  persist  or  increase  after  months  or  even  a 
year  of  extension,  when  the  patient's  life  is  threatened  by  sepsis  the 
result  of  cystitis  or  bed  sores,  when  the  posterior  arches  are  diseased, 
or  when  the  compression  is  acute  in  onset,  indicating  bony  displace- 
ment. 

Spinal  meningitis  extends  from  the  membranes  of  the  brain  or 
begins  as  a  local  affection.  Pachymeningitis  may  follow  disease  or 
injury  of  the  vertebrae  and  is  often  syphilitic  or  tuberculous  in  nature. 
A  hemorrhagic  pachymeningitis  interna  analogous  to  that  found  in 
the  head,  occurs  chiefly  in  the  cervical  region.  The  symptoms  of 
pachymeningitis  are  first  those  of  irritation  of  the  nerve  roots,  i.e. 
shooting  pains  and  perhaps  spasms  in  the  parts  supplied  by  the 
nerves,  and  later  those  of  a  gradually  oncoming  compression  of  the 
cord.  The  treatment  is  removal  of  the  cause,  rest,  and  potassium 
iodid.     Laminectomy  may  be  indicated  in  the  later  stages. 

Acute  leptomeningitis  may  follow  disease  or  injury  of  the  spinal 
column,  or  wounds  of  the  membranes.  It  usually  extends  to  the 
cerebral  meninges,  and  then  presents  the  symptoms  described  under 
inflammation  of  the  latter  structure,  and  is  treated  by  the  same 
means.     Chronic     leptomeningitis     may     follow    the    acute    form. 


564  MANUAL    OF    SURGERY 

When  chronic  from  the  beginning  it  is  usually  localized,  and  is 
prone  to  attack  the  syphilitic  and  alcoholic.  The  symptoms  are 
localized  pain  in  the  back,  rigidity  of  the  spinal  muscles,  and  evi- 
dences of  irritation  of  the  nerve  roots  as  described  above.  If  granu- 
lations form,  the  symptoms  will  be  similar  to  those  of  tumor.  The 
treatment  is  rest,  counter-irritation,  sedatives,  potassium  iodid,  and 
laminectomy  if  pressure  symptoms  ensue. 

Intraspinal  tumors  are  generally  gliomata,  gummata,  or  tuber- 
culous masses.  Lipoma  (usually  congential),  fibroma,  angioma, 
myxoma,  chondroma,  hydatid  and  dermoid  cysts,  secondary  car- 
cinoma, and  sarcoma  also  occur.  The  tumor  may  be  extradural, 
subdural,  or  intramedullary.  The  symptoms  are  those  of  a  gradually 
oncoming  compression  with  perhaps  localized  pain  and  tenderness 
over  the  segment  involved.  The  disturbances  of  motion,  sensation, 
and  of  the  reflexes,  develop  from  below  upward  and  are  often  at 
first  unilateral.  In  the  beginning  the  symptoms  are  those  of  irrita- 
tion, i.e.,  shooting  pains,  hyperesthesia,  localized  spasms  (perhaps 
causing  lateral  curvature,  the  concavity  being  on  the  side  of  the 
tumor),  and  increased  reflexes.  Later  there  are  paresis,  hypesthesia, 
and  decrease  of  reflexes,  and  finally  paralysis,  anesthesia,  loss  of 
reflexes,  and  trophic  disturbances.  Motion  is  usually  affected 
before  sensation,  but  this  will  necessarily  depend  somewhat  on  the 
situation  of  the  growth.  The  pupils  may  be  affected  if  the 
lesion  is  above  the  second  dorsal  segment.  The  diagnosis  of  the 
nature  of  the  growth  is  usually  impossible,  although  a  previous  history 
of  syphilis,  tuberculosis,  or  a  malignant  growth  elsewhere,  should 
be  sought;  a  tumor  occurring  soon  after  birth  would  probably  be  a 
lipoma.  The  X-ray  and  the  Wassermann  and  tuberculin  tests  also 
may  give  valuable  information.  The  seat  of  the  tumor  is  determined 
by  the  localizing  symptoms  (see  spinal  localization).  Intramedullary 
growths  usually  produce  bilateral  symptoms  and  earlier  signs  of 
compression.  ExtrameduUary  growths  are  apt  to  cause  earlier 
and  more  severe  signs  of  irritation.  Chronic  inflammation  of  the 
meninges  or  cord  may  produce  similar  symptoms.  The  prognosis 
is  much  more  favorable  than  in  cerebral  tumors.  About  one-half 
are  operable  and  about  one-half  of  those  operated  upon  are  benefited. 
The  mortality  of  operation  is  10  per  cent. 

The  treatment,  if  syphihs  and  metastatic  growths  can  be  ex- 
cluded, is  laminectomy  and  removal  of  the  tumor. 

Infantile  paralysis  {acute  anterior  poliomyelitis)  usually  occurs 
within  the  first  three  years  of  life,  is  mildly  contagious,  and  due  to  a 
specific   micro-organism    (Flexner    and    Noguchi),    whose   point    of 


SPINE  565 

ingress  and  egress  is  the  nasal  mucous  membrane.  The  biting  stable 
fly  (stomoxys  calcitrans)  and  ])robably  also  the  common  fly  and  the 
bedbug  transmit  the  disease.  It  is  characterized  by  slight  fever, 
and  sudden  paralysis  of  a  group  of  muscles,  followed  by  rapid 
atrophy  because  of  the  destruction  of  their  trophic  centers  in  the 
anterior  horns  of  the  cord.  The  face  and  neck  are  very  rarely 
involved,  but  the  muscles  of  the  back  and  abdomen  may  be  affected. 
In  the  upper  extremity  the  deltoid,  brachialis  anticus,  biceps, 
supinator  longus,  extensors  or  flexors  of  the  wrist  or  iingers  may  be 
attacked;  in  the  leg,  the  favorite  site,  the  tibials  anticus  and  other 
muscles  on  the  front  of  the  leg;  and  in  the  thigh  the  quadriceps  and 
the  adductors.  The  surgical  treatment,  in  the  early  stages,  is  to 
prevent  deformity  and  increase  the  nutrition  of  the  muscles  by 
massage,  electricity,  passive  and  active  motions,  and  special  shoes  or 
braces,  either  during  the  night,  or  in  bad  cases  also  during  the  day. 
When  deformity  has  developed,  various  measures  may  be  indicated 
in  addition  to  the  above:  forcible  correction  under  an  anesthetic, 
tenotomy,  fasciotomy,  myotomy,  tendon  transplantation,  nerve 
transplantation,  osteotomy,  arthrodesis,  or  rarely  amputation  when 
a  limb  is  absolutely  useless. 


CHAPTER  XXIII 
EAR,  NECK,  THYROID  GLAND 
THE  EAR 

Only  those  conditions  peculiar  to  the  ear  which  more  or  less 
directly  concern  the  surgeon  will  be  considered  in  this  chapter. 

The  external  ear  may  be  abnormally  small  (microtia),  or  it  may  be 
completely  or,  more  commonly,  partly  absent,  and  such  defects  can 
rarely  be  benefited  by  plastic  surgery.  Accessory  auricles  should  be 
amputated.  Congenital  fistulaeand  fissures  are  the  result  of  incom- 
plete closure  of  the  first  branchial  cleft;  the  former  may  be  excised, 
the  latter  sutured  after  paring  the  edges.  Very  large  ears(niacrotia) 
have  been  reduced  in  size  by  the  removal  of  a  wedge-shaped  section 
from  the  upper  part  of  the  pinna  with  subsequent  suture.  Promi- 
nent ears  may  be  brought  closer  to  the  head  by  the  excision  of  an 
elliptical  portion  of  the  skin  on  the  posterior  aspect  with  subsequent 
suture,  or  by  denuding  the  groove  between  the  ear  and  the  skull  and 
closing  the  wound  with  sutures.  Woimds  of  the  auricle  are  often 
slow  in  healing  and  are  occasionally  followed  by  necrosis  of  the  car- 
tilage; if  the  meatus  is  involved  it  may  be  necessary  to  graft  skin 
to  prevent  atresia.  Loss  of  a  portion  of  the  ear  may  be  supplied  by  a 
pedunculated  flap  from  the  neighboring  skin,  the  pedicle  being  cut 
after  union  has  taken  place  {otoplasty) ;  artificial  ears  of  papier- 
mache  or  metal  are  usually  more  slightly  than  the  shapeless  mass 
which  generally  follows  an  attempted  otoplasty  when  the  entire 
auricle  has  been  lost.  Hematoma  of  the  ear  [othematoma)  generally 
occupies  the  concavity  of  the  auricle,  the  blood  separating  the 
perichondrium  from  the  cartilage.  It  follows  injury  [boxers  ear), 
or  occurs  spontaneoulsy,  most  frequently  in  the  insane,  and  is  then 
apt  to  be  followed  by  great  thickening  and  distortion.  The  treatment 
is  aspiration,  and  pressure  by  means  of  bandage.  Should  suppuration 
occur,  a  free  incision  will  be  needed. 

Inflammatory  affections  and  tumors  of  the  external  ear  present 
the  same  features  and  require  the  same  treatment  as  elsewhere. 

Atresia  of  the  meatus,  congenital  or  acquired,  when  membranous 
in  character  may  be  treated  by  excision  of  the  membrane  and  skin 
grafting. 

Impacted  cerumen  (plugs  of  wax)  causes  diminution  in  hearing, 

566 


EAR,  NECK,  THYROID  GLAND  567 

tinnitus,  and  sometimes  vertigo  and  inflammatory  troubles.  The 
diagnosis  is  made  by  the  speculum.  The  Ireatment  is  removal  by 
syringing  with  warm  bicarbonate  of  soda  solution.  The  wax  may 
first  be  softened  by  having  the  patient  retain  in  the  ear  for  fifteen 
minutes  or  longer  a  mixture  of  glycerin  and  water. 

Foreign  bodies  also  are  removed  by  syringing.  Live  insects  may 
be  killed  with  sweet  oil;  if  fastened  to  the  wall  of  the  canal  it  will  be 
necessary  to  use  angular  forceps  to  remove  them,  the  ear  being 
illuminated  with  a  head  mirror.  Vegetable  bodies  which  swell 
should  be  removed  at  once  by  instrumental  means  if  syringing  fails. 
If  unskilled,  one  may  do  much  harm  with  instruments  in  the  ear, 
hence  if  syringing  fails  the  case  should  be  referred  to  an  otologist. 
Rarely  will  it  be  necessary  to  turn  the  auricle  forwards  and  enter  the 
meatus  from  behind. 

The  surgical  complications  of  suppurative  otitis  media  are  often 
of  the  gravest  nature,  consequently  this  condition  should  never  be 
neglected.  Pyeinia,  even  without  local  complications  may  occur, 
and  miliary  tuberculosis  occasionally  develops  when  the  affection  is 
tuberculous  in  nature.  The  local  complications  may  be  (i)  extra- 
cranial, (2)  cranial,  or  (3)  intracranial. 

1.  The  extracranial  complications  are  eczema  2j\6.  fnnmcles  of  the 
meatus,  cervical  adenitis,  and  suppurative  arthritis  of  the  temporo- 
maxillary  joint. 

2.  The  cranial  complications. — Carious  or  necrotic  ossicles  may 
be  removed  through  the  meatus,  and  disease  of  adjacent  bone  is 
occasionally  treated  in  the  same  way,  but  more  frequently  a  mastoid 
operation  will  be  required  and  the  disease  can  then  be  dealt  with  from 
behind. 

Granulations  and  polypi  may  dam  up  the  discharge,  and  are 
removed  by  the  currette,  forceps,  or  snare. 

Suppuration  of  the  labyrinth  can  be  treated  only  by  providing  free 
drainage  of  the  tympanum;  there  is  considerable  danger  of  extension 
to  the  brain. 

Facial  paralysis  is  due  to  neuritis,  pressure  being  exerted  by  the 
increase  in  the  size  of  the  nerve  and  the  thickening  of  its  osseous 
canal.  The  nutrition  of  the  facial  muscles  should  be  maintainedby 
electricty  and  massage,  and  if  no  signs  of  recovery  appear  after  six 
months,  the  nerve  may  be  anastomosed  with  the  spinal  accessory  or 
the  hypoglossal  (see  chap.  xvii). 

Fatal  hemorrhage  from  erosion  of  the  internal  carotid,  internal 
jugular,  middle  meningeal,  or  lateral  or  petrosal  sinus  is  a  rare  but 
possible  complication. 


568  MANUAL    OF    SURGERY 

Mastoiditis  of  some  degree  is  probably  associated  with  every 
acute  suppurative  otitis  media,  but  if  the  tympanum  is  promptly 
drained,  no  ill  effects  need  follow.  The  mucous  membrane  alone  may 
be  involved,  but  what  is  recognized  clinically  as  mastoiditis  is  usually 
an  osteomyelitis.  There  may  be  a  desquamative  inflammation  which 
fills  the  cavities  with  cholesteatomatous  material.  Although  the 
mastoid  antrum  is  present  at  birth,  the  mastoid  cells  and  the  mastoid 
process  are  not  well  developed  until  after  puberty.  These  cells 
surround  and  communicate  with  the  antrum  and  are  very  variable 
in  extent;  they  may  extend  forwards  above  the  meatus,  backwards 
to  the  occipital  bone,  upwards  to  the  parietal  bone,  and  downwards 
to  the  apex  of  the  mastoid. 

The  S3miptoms  are  pain  and  tenderness,  both  of  which  may 
however,  be  absent  in  chronic  cases  with  a  thick  cortex  or  limited  dis- 
ease. In  acute  cases  there  may  be  fever  and  leukocytosis.  The 
most  important  sign  is  edema  and  bulging  of  the  upper  posterior 
wall  of  the  auditory  meatus.  If  the  infection  spreads  outwards 
there  will  be  redness  and  edema  of  the  skin  over  the  mastoid  and 
possibly  the  formation  of  a  subperiosteal  abscess,  which  may  perfor- 
ate and  form  a  subcutaneous  collection  of  pus.  or  spread  downwards 
and  give  rise  to  a  cellulitis  of  the  neck.  Extension  inwards  through 
the  tegmen  tympani  may  cause  inflammation  of  the  external  semi- 
circular canal  or  the  facial  nerve;  upwards,  abscess  on  either  side  of 
the  dura,  septic  meningitis,  or  cerebral  abscess;  downwards,  deep 
celluHtis  of  the  neck;  forwards,  a  sinus  of  the  meatus;  and  backwards, 
thrombosis  of  the  lateral  sinus  or  abscess  of  the  cerebellum.  Often 
the  discharge  from  the  ear  abates  when  the  mastoid  symptoms  are 
active.     A  skiagraph  is  usually  of  value  in  diagnosis. 

The  treatment  in  acute  cases  with  pain  and  tenderness  only, 
is  draining  and  cleansing  of  the  tympanum,  cold  to  the  mastoid, 
and  the  artificial  leech.  If  the  symptoms  persist  for  several  days, 
or  if  there  is  external  edema,  continuous  headache,  or  constitutional 
symptoms,  the  mastoid  should  be  opened  and  drained.  A  mastoid 
operation  is  indicated  likewise  in  cases  of  incurable  chronic  otorrhea 
even  when  there  are  no  symptoms  of  mastoiditis.  In  acute  mastoid- 
itis the  Schwartze  operation,  or  simple  opening  of  the  antrum  with 
drainage,  may  be  all  that  is  required.  In  chronic  cases  it  will  be 
necessary  to  clean  out  and  convert  into  one  cavity  the  antrum,  attic 
tympanum,  and  meatus  (Schwartze-Stacke  operation). 

In  the  Schwartze  operation  the  antrum  may  be  opened  with  a 
trephine,  awl,  gimlet,  or  with  a  bur  propelled  by  a  surgical  engine 
but  probably  most  surgeons  use  a  gouge  or  a  chisel.     A  curved 


EAR,  NECK,  THYROID  GLAND  569 

incision  is  made  about  one-fourth  inch  posterior  to  and  parallel  with  the 
insertion  of  the  auricle,  from  above  the  ear  to  the  tip  of  the  mastoid, 
the  flap  including  the  periosteum  pushed  forwards,  the  mastoid 
vein  examined  for  thrombosis  (indicating  thrombosis  of  the  lateral 
sinus)  and  the  bone  for  sinuses.  In  the  absence  of  a  sinus,  which 
should  be  followed  if  present,  the  antrum  is  opened  in  Macewen's 
suprameatal  triangle,  which  is  bounded  above  by  the  posterior  root  of 
the  zygoma,  in  front  by  the  posterior  wall. of  the  external  meatus,  and 
behind  by  a  line  joining  these  two.  With  the  ear  pulled  well  forward 
this  triangle  can  be  recognized  as  a  depression  in  the  bone.  In  young 
children  the  antrum  may  be  perforated  with  a  curette.  In  adults 
the  chisel  or  gouge,  one-fourth  inch  in  width,  may  be  used,  thin  slices 
of  bone  being  removed  in  a  direction  downwards,  forwards,  and  slightly 
inwards.  Unless  the  bone  is  thickened  the  mastoid  cells  will  be 
encountered  just  below  the  surface.  The  antrum,  too,  is  superficial 
in  the  child,  but  in  the  adult  its  depth  beneath  the  surface  of  the 
bone  varies  from  one-eight  to  three-fourths  of  an  inch.  One  should 
never  penetrate  more  than  three-fifths  of  an  inch  from  the  anterior 
edge  of  the  external  opening,  because  of  the  danger  of  wounding  the 
facial  nerve  or  the  external  semicircular  canal.  The  opening  should 
be  enlarged,  and  all  infected  cells  removed  with  curette,  gouge,  or 
rongeur.  The  dura  and  sigmoid  sinus  need  not  be  feared  if  care  is 
taken  to  remove  very  thin  slices  of  bone,  and  to  explore  the  minutest 
opening  with  a  probe.  The  cavity  is  smoothed  with  the  curette, 
irrigated  with  salt  solution,  packed  with  gauze,  and  the  external 
wound  partly  closed. 

In  the  Schwartze-Stacke operation  the  antrum  and  all  the  mastoid 
cells  are  obliterated  as  described  above,  remembering  the  extreme 
limits  at  which  these  cells  may  be  found.  The  postero-superior  wall 
of  the  meatus  is  next  removed  almost  as  far  as  the  floor  of  the  meatus, 
but  sloping  upwards  in  the  deeper  parts  to  avoid  the  facial  nerve. 
The  remains  of  the  tympanic  membrane,  malleus,  and  incus  are 
removed.  A  probe  may  be  passed  through  the  opening  between  the 
antrum  and  attic,  to  protect  the  facial  nerve  and  the  external 
semicircular  canal,  which  He  behind,  while  the  bone  in  front  including 
the  outer  wall  of  the  attic  is  removed.  The  inner  wall  and  floor 
of  the  antrum  should  not  be  disturbed,  because  of  the  danger  of 
injury  to  the  facial  nerve  or  external  semicircular  canal.  After 
smoothing  the  walls  of  the  cavity  and  irrigating  with  salt  solution 
the  posterior  wall  of  the  cartilaginous  meatus  is  split  longitudinally, 
and  the  flaps  thus  formed  stitched  to  the  posterior  margin  of  the  skin 
wound,  so  that  the  whole  cavity  can  be  inspected  through  the  meatus. 


570  MANUAL    OF    SURGERY 

The  operation  is  completed  by  filling  the  cavity  with  gauze,  intro- 
duced through  the  meatus  and  posteriorly,  and  by  partly  closing  the 
wound  in  the  skin.  When  granulations  have  covered  the  bones 
heahng  may  be  faciUtated  by  the  use  of  Thiersch's  skin  graft. 

3.  The  intracranial  complications  of  otorrhea  are  thrombosis  of  the 
lateral  sinus,  meningitis,  and  extradural,  cerebral,  or  cerebellar 
abscess  (see  chapter  on  the  Head). 

THE  NECK 

In  the  development  of  the  face  and  neck  five  processes  {branchial 
arches)  are  formed  on  each  side,  and  between  these  arches  are  the 
four  branchial  clefts.  The  first  arch  joins  its  fellow  in  the  middle 
line  to  form  the  lower  jaw,  the  malleus  developing  from  its  upper 
end.  A  process  from  the  base  of  this  arch  extends  forward  to  join 
the  fronto-nasal  process  jutting  down  from  above,  and  forms  the 
upper  jaw;  when  these  processes  fail  to  unite,  cleft  palate  and  harelip 
result,  The  second  arch  forms  the  incus,  stapes,  styloid  process 
stylohyoid  ligament,  and  lesser  cornu  of  the  hyoid  bone.  The 
remains  of  the  cleft  between  the  first  and  the  second  arch  is  seen  as 
the  Gasserian  fissure,  external  auditory  meatus,  tympanum,  and 
Eustachian  canal.  The  tonsil  is  formed  from  the  second  branchial 
cleft.  The  third  arch  forms  the  body  and  greater  cornu  of  the 
hyoid  bone,  the  thymus  gland  and  parathyroids  bodies  are  formed 
from  the  third  branchial  cleft  while  the  rest  of  the  neck  develops 
from  the  remaining  arch.  A  rudimentary  fourth  branchial  cleft 
or  the  fifth  arch  may  give  rise  to  a  post  branchial  growth. 

Branchial  fistulae  result  from  imperfect  closure  of  the  branchial 
clefts;  they  open  on  the  skin,  in  the  pharynx,  or  in  both  places. 
During  the  closure  of  branchial  clefts  (gill  clefts)  portions  of  the  walls 
of  the  clefts  may  become  enclosed  within  the  tissues  of  the  neck 
causing  various  sorts  of  tumors  and  cysts.  If  derived  from  the 
external  furrows,  they  are  dermoid  in  character,  lined  with  ecto- 
dermal derivatives,  and  contain  sebaceous  matter.  If  derived  from 
internal  furrows  they  contain  mucous  fluid,  the  Hning  epithelium 
is  likely  to  be  columnar  and  sometimes  ciliated.  Fistulae  and  fissures 
in  the  neighborhood  of  the  ear  are  vestiges  of  the  first  branchial  cleft. 
Congenital  fistulae  of  the  neck  are  most  frequent  in  the  neighborhood 
of  the  fourth  cleft  and  open  externally  at  the  anterior  edge  of  the 
sternomastoid  closer  to  its  lower  end.  Fistulae  at  the  anterior  or 
posterior  edge  of  the  sternomastoid  at  the  level  of  the  larynx  are  the 
remains  of  the  second  or  third  cleft.     The  internal  opening  is  usually 


EAR,    NFXK,    THYROID    GLAND 


571 


in  the  lower  part  of  tlu-  j)luir\  iix  or  behind  the  tonsil.  An  incomplete 
internal  listula  may  cause  a  congenital  diverticulum  of  the  esophagus. 
Of  similar  origin  are  some  median  fistula),  which  may  open  into  the 
trachea  or  larynx,  and  which  when  incomplete  internally  may 
beget  air  tumors  {laryngocelc  or  tracheocele).  Other  median  fistulae 
are  due  to  a  patent  thyroglossal  duct,  which  in  the  embryo  passes 
from  the  isthmus  of  the  thyroid  gland  up  in  front  of  the  trachea  and 
larynx,  then  behind  or  through  the  body  of  the  hyoid  bone,  to  open 
at  the  foramen  cecum  of  the  tongue.  Accessory  thyroids  may  spring 
from  any  portion  of  this  duct.  All  these  fistulae  are  lined  by  mucous 
membrane  and  hence  give  rise  to  a  mucoid  discharge. 


Fig.  283. — Hydrocele  of  neck. 


Cysts  of  the  neck  may  be  congenital  or  acquired. 

Congenital  cysts,  which  may  not  appear  for  some  years  after 
birth,  include  the  branchial,  thyroglossal  (either  of  which  may  be 
mucoid  or  dermoid),  and  blood  cysts,  and  cystic  lymphangioma. 
Branchial  cysts  arise  from  unobliterated  portions  of  the  branchial 
clefts,  and  usually  lie  beneath  the  muscles  of  the  tongue  or  behind 
the  sternomastoid;  in  the  former  situation  they  may  be  mistaken 
for  ranulae,  in  the  latter  they  are  often  closely  connected  with  the 
great  vessels.  They  are  lined  by  epithelium  and  contain  a  serous  or 
mucoid  material  {hygroma,  hydrocele  of  the  neck — Fig.  283),  or  sebum, 
hair,  teeth,  etc.  (dermoids) .  Thyroglossal  cysts  arise  from  any  portion 
of  the  thyroglossal  duct,  hence  are  median  in  position;  they  may 


572  MANUAL    OF    SURGERY 

contain  mucus  or  dermoid  material.  Sublingual  dermoids  and 
subhyoid  cysts  belong  to  this  class.  Blood  cysts  probably  arise  from  a 
congenital  diverticulum  of  one  of  the  large  veins  of  the  neck;  if 
the  communication  persists,  they  may  be  reduced  by  pressure,  and 
vary  in  size  during  respiration.  Cystic  lymphangioma  (Fig.  84), 
sometimes  improperly  called  cystic  hygroma,  is  due  to  dilated 
lymph  vessels  and  spaces,  hence  is  multilocular  and  lobulated;  it 
may  spread  to  the  face  "and  into  the  thorax  and  is  then  beyond 
operative  aid. 

Acquired  cysts  may  be  sebaceous  (chap,  xivj,  hydatid  (chap. 
xiii).  thyroid  (see  cystic  goiter),  bursal,  or  malignant.  Bursal 
cysts  may  develop  over  the  thyroid  cartilage,  or  between  it  and  the 
hyoid  bone.  Occasionally  one  encounters  a  carcinoma  deep  in  the 
cervical  tissues  without  finding  a  primary  growth  elsewhere.  These 
cases  may  be  regarded  as  branchiogenic  carcinoma  of  glandular 
tvpe  derived  from  embryonic  inclusions  of  epithelium  derived  from 
infolding  of  ectoderm  forming  the  inner  clefts;  if  squamous  celled 
from  either  entoderm  or  ectoderm.  After  a  time  they  undergo 
cystic  degeneration  (malignant  cysts  of  the  neck),  or  break  down 
into  a  puruloid  material,  and  may  superficially  resemble  a  chronic 
cellulitis  of  the  neck.  Sarcoma  of  the  neck  likewise  may  undergo 
cystic  degeneration.  The  treatment  of  all  the  conditions  mentioned 
above  is  excision,  which  is  often  a  difficult  matter.  Fistulae  and 
cysts  which  cannot  be  excised  may  be  opened,  and  the  lining  mem- 
brane destroyed  by  cauterization.  Blood  cysts  may  necessitate 
suture  or  ligature  of  the  jugular  or  subclavian  vein. 

Torticollis,  or  wry  neck,  is  a  deformity  in  which  the  head  is  bent 
towards  the  shoulder,  and  the  face  turned  towards  the  opposite  side 

False  torticollis  is  seen  in  cases  like  fracture  of  the  clavicle,  and 
tumors  and  inflammations  of  the  neck;  it  results  also  from  rheuma- 
tism or  cold  (stiff  neck)  and  hysteria.  The  treatment  is  directed  to 
the  cause. 

True,  or  chronic  torticollis,  may  be  (i)  spasmodic  or  (2)  perma- 
nent. I.  Spasmodic  torticollis  (tonic  or  clonic)  usually  affects  one 
sternomastoid  only,  but  occasionally  that  of  the  opposite  side  as  well 
as  the  posterior  deep  cervical  muscles  also  are  involved,  so  that  the 
head  is  drawn  backwards  {retrocollis) .  The  spasm  may  be  persistent, 
or  it  may  intermit  for  days  or  weeks,  but  in  either  event  it  is  usually 
absent  during  sleep.  It  may  result  from  direct  irritation  of  the  nerve 
supplying  the  muscles,  e.g.,  by  tumors,  enlarged  glands,  cervical 
caries;  or  from  reflex  irritation,  such  as  carious  teeth,  worms,  and 
pelvic  troubles;  but  is  usually  seen  in  the  neurotic  and  hysterical  and 


EAR.    NECK,    THYROID    GLAXI) 


573 


may  possibly  hr  diu'  to  irritation  of  the  motor  centers.  I'he  treatment 
is  removal  of  any  source  of  irritation,  the  treatment  of  any  associated 
neurosis,  and  the  administration  of  antispasmodics.  If  these  meas- 
ures fail,  the  spinal  accessory  nerve  may  be  stretched  or  severed; 
the  posterior  cervical  nerves  may  be  similarly  treated  if  the  posterior 
cervical  muscles  also  are  affected. 

2.  Permanent  torticollis  is  the  result  of  malformation,  vicious 
intrauterine  position,  or  prenatal  disease  of  the  muscle  or  nerves 
{congenital  torticollis) ;  it  may  be  caused  also  by  strabismus,  scoliosis, 


Fig.   284. — Congenital  torticollis.      The  X-ray  showed  areas  of  ossification  in  the  con- 
tracted sternomastoid  and  a  large  exostosis  at  its  clavicular  insertion. 


paralysis  of  the  opposite  muscle,  or  by  cicatricial  shortening  of  the 
muscle  or  surrounding  tissues,  following  laceration  at  birth  or  subse- 
quent injuries  or  inflammations.  The  sternomastoid  alone  may  be 
at  fault,  or  the  trapezius  and  deeper  muscles  also  may  be  implicated 
and  the  deep  cervical  fascia  shortened.  In  congenital  cases  (Fig. 
284)  or  those  arising  soon  after  birth,  the  face  of  the  aft'ected  side 
fails  to  develop  as  rapidly  as  the  sound  side.  A  compensatory 
lateral  curve,  concave  towards  the  affected  side,  develops  in  the 
cervical  spine,  and  a  secondary  dorsal  curve,  concave  in  the  opposite 
direction,  is  formed,  leading  to  changes  in  the  shape  of  the  vertebrae. 


574  MANUAL    OF    SURGERY 

The  treatment  in  early  cases  is  masage,  manipulations  to  straighten 
the  head,  and  a  brace  or  support  to  maintain  the  corrected  position. 
Any  contributory  lesion,  such  as  strabismus,  scoliosis,  etc.,  likewise 
should  receive  attention.  In  most  cases,  however,  little  progress 
can  be  made  until  the  sternomastoid  muscle  has  been  divided.  The 
subcutaneous  operation  for  this  purpose  is  unsafe  and  incomplete 
and  will  not  be  described.  In  the  open  method  the  muscle  is  isolated 
and  divided  through  a  transverse  incision  about  one-half  inch  above 
the  clavicle,  the  skin  is  then  sutured,  and  the  head  fixed  in  the  cor- 
rected position  by  plaster-of-Paris  or  other  apparatus.  Mikulicz 
removes  the  entire  muscle  as  far  as  the  spinal  accessory  nerve. 

Cervical  rib  springs  from  the  anterior  transverse  process  of  the 
seventh  cervical  vertebra.  It  is  bilateral  in  about  two-thirds  of  the 
cases;  more  common  in  females;  rarely  a  second  cervical  rib  may- 
arise  from  the  sixth  cervical  vertebra.  The  anterior  extremity  is 
usually  free,  but  it  may  unite  with  the  first  rib  or  with  even  the  stern- 
um. The  brachial  plexus  and  subclavian  artery  pass  over  it,  and 
with  the  growth  of  the  rib  or  its  ossification  these  structures  are 
compressed,  causing  pain,  weakness  of  the  arm,  trophic  troubles,  or 
even  obliteration  of  the  pulse  and  gangrene.  It  may  be  mistaken  for 
neuritis  from  other  causes,  Ra}'naud's  disease,  as  well  as  aneurysm. 
There  is  no  edema  of  the  arm,  i3ecause  the  subclavian  vein  lies  in 
front  of  the  scalenus  anticus  muscle  and  escapes  pressure.  The 
rib  forms  a  prominence  in  the  neck,  which  has  been  mistaken  for 
aneurysm,  because  it  pushes  the  subclavian  artery  forwards  and 
upwards.  The  X-ray  will  dispel  all  doubt.  If  there  are  pressure 
symptoms,  the  rib  may  be  removed  through  a  transverse  incision 
after  separating  the  nerves  and  vessels. 

Cellulitis  of  the  neck  is  usually  secondary  to  infections  in  the  area 
drained  by  the  cervical  lymph  glands,  but  may  follow  also  cold, 
injury,  and  acute  infectious  fevers.  The  process  varies  greatly 
according  to  its  situation,  the  virulency  of  the  infection,  and  the  resist- 
ance of  the  individual;  thus  it  may  be  superficial  or  deep  (with  refer- 
ence to  the  cervical  fascia),  circumscribed  or  diffuse,  acute  or  chronic. 
Superficial  inflammatory  troubles  of  the  neck  differ  Httle  from  Hke 
lesions  elsewhere  and  require  no  special  mention.  Deep  celluHtis  or 
abscess  is  often  of  the  gravest  nature  because  of  the  danger  of  exten- 
sion to  the  axilla,  mediastinum,  'or  pleura,  rupture  into  the  trachea 
or  esophagus,  or  edema  of  the  glottis.  External  fluctuation  and 
pointing  are  the  exception.  In  addition  to  the  general  septic 
symptoms  the  neck  is  swollen  and  hardened  and  the  skin  red  and 
edematous.     The  head  is  bent  towards  the  affected  side,  and  there 


EAR,  NECK,  THYROID  GLAND  575 

may  be  dysphagia,  dysj^nca.  and  SNiiij^ttoms  of  pressure  on  Ihe  vessels 
or  nerves.  A  streptococcic  cellulitis  of  the  sublingual  and  submental 
region  is  called  angina  Ludovici.  The  floor  of  the  mouth,  the  inter- 
muscular and  su])cutaneous  tissues  of  the  submaxillary  region  are 
involved  in  a  tense  phlegmon  which  tends  toward  gangrene.  A 
chronic  form  of  cellulitis  of  the  neck  with  little  or  no  pain  and  fever 
and  presenting  a  board-like  inflammatory  hardness,  has  been  des- 
cribed by  Reclus  under  the  term  phlegmone  ligneuse  du  cou,  or  woody 
phlegmon  of  the  neck.  After  a  time  a  small  abscess  forms  and 
healing  ensues,  although  in  one  case  death  was  due  to  edema  of  the 
glottis.  These  cases  resemble  a  carcinomatous  infiltration  of  the 
neck. 

The  treatment  in  acute  cases  is  prompt  incision,  never  waiting  for 
fluctuation.  A  general  anesthetic  should  not  be  given  if  pus  is 
discharging  into  the  mouth  or  there  is  trismus.  An  abscess  may  be 
opened  by  Hilton's  plan  (see  abscess).  Tracheotomy  is  sometimes 
necessary.  The  constitutional  symptoms  of  sepsis  should  be  com- 
bated. 

Cut  throat  may  be  homicidal  or  suicidal.  In  the  latter  the  wound 
is  usually  between  the  hyoid  bone  and  the  larynx  and  deepest  on  the 
side  opposite  to  the  hand  employed.  In  either  case,  however,  the 
wound  varies  both  as  to  depth  and  to  situation,  and  any  of  the  struc- 
tures of  the  neck  may  be  involved.  The  effects  of  division  of  the 
nerves  have  already  been  mentioned.  The  diagnosis  of  a  wound  of 
the  air  passages  is  easily  made.  Injury  to  the  esophagus  is  much 
less  common  and  may  be  accompanied  by  hematemesis,  dysphagia, 
and  the  escape  of  mucus  or  food  through  the  wound.  The  immediate 
dangers  are  shock,  hemorrhage,  air  embolism,  and  asphyxia  due  to 
blood  or  displaced  structures.  The  secondary  dangers  are  cellulitis 
septicemia,  pyemia,  edema  of  the  glottis,  secondary  hemorrhage, 
inspiration  pneumonia,  and  emphysema  of  the  cellular  tissues. 

The  treatment  is  arrest  of  hemorrhage,  even  the  smallest  bleeding 
point  being  attended  to,  because  of  the  danger  of  blood  trickling  into 
the  air  passages;  removal  of  clots  from  the  trachea;  saline  infusion 
and  other  means  to  combat  shock;  disinfection  of  the  wound;  and 
suture  of  divided  nerves,  esophagus,  trachea,  larynx,  and  muscles. 
Drainage  should  be  employed  in  order  to  provide  a  vent  for  blood, 
air,  or  esophageal  secretions.  In  an  extensive  transverse  wound  of 
the  trachea  the  sutures  almost  invariably  tear  out.  If  the  larynx 
has  been  opened,  safety  demands  the  performance  of  a  high  tracheot- 
omy, as  breathing  is  sure  to  be  obstructed.  The  neck  is  dressed 
with  the  head  flexed  on  the  chest,  and  the  patient  fed  per  rectum  or 


576  MANUAL    OF    SURGERY 

through  a  tube  in  the  esophagus,  if  that  structure  has  not  been 
wounded. 

Among  the  sequelce  may  be  mentioned  stenosis  of  the  larynx, 
esophagus,  or  trachea  (q.v.) ;  esophageal  fistula,  which  usually 
closes  after  a  time;  aerial  fistula,  which  if  persistent  may  be  closed 
by  freshening  and  suturing  the  opening  in  the  air  passage,  care  being 
taken  first  to  make  sure  that  there  is  no  stenosis  above;  and  lesions 
which  may  follow  division  of  nerves,  e.g.,  aphonia  from  a  severed 
recurrent  laryngeal  nerve. 

THE  THYROID  GLAND 

The  parathyroid  glands  are  four  in  number.  They  are  brownish 
red,  oval  bodies,  about  one-fourth  inch  in  length,  lying  upon  the 
posterior  surface  of  the  capsule  of  the  thyroid  gland,  one  near  the 
pole  of  each  lobe.  Each  parathyroid  has  a  terminal  artery,  usualh' 
derived  from  the  anastomotic  branch  between  the  superior  and  infe- 
rior thyroid  arteries.  A  knowledge  of  the  existence  and  situation 
of  these  bodies  is  of  great  importance  to  the  surgeon,  as  their  destruc- 
tion results  in  tetany,  severe  and  fatal  if  none  is  left,  milder  if  one 
or  two  remain.  In  about  10  per  cent,  or  more  of  lobectomies  (so 
called  intra  capsular)  parathyroids  are  removed,  but  no  tetany  fol- 
io w^s,  those  on  the  other  side  being  sufficient.  Poole  says  that  at 
least  one  lobe  must  always  be  left.  In  3203  goitre  operated  upon 
the  Mayos  report  only  one  case  of  tetany.  The  symptoms  of  this 
tetany  parathyreopriva.  as  it  is  called,  are  those  of  other  forms  of 
tetany,  for  which  the  student  is  referred  to  a  text-book  on  medicine. 
The  treatment  is  administration  of  parathyroid  extract  or  serum, 
and  calcium  lactate,  in  a  5  per  cent,  solution,  by  mouth,  rectum,  or 
intravenously;  transplantation  of  parathyroids  from  animals  also 
has  been  tried. 

Wounds  of  the  thyroid  cause  severe  bleeding,  which  may  be 
checked  by  sutures  or  by  gauze  packing.  In  some  cases  it  may  be 
necessary  to  extirpate  the  gland. 

Accessory  thyroids  may  be  found  about  the  thyroid  gland,  in 
the  upper  portion  of  the  chest,  or  along  the  course  of  a  thyroglossal 
duct  as  far  as  the  base  of  the  tongue  {lingual  goiter) .  If  increasing 
in  size  or  causing  pressure  symptoms,  medical  treatment  as  de- 
scribed below  may  be  tried  for  a  time,  but  will  usually  fail,  and  then 
extirpation  should  be  performed,  first  making  sure  that  the  normal 
thyroid  is  present,  as  the  accessory  gland  may  be  the  only  one  the 
patient  has,  and  its  removal  would  then  be  followed  by  myxedema^ 


EAR.  NECK,  THYROID  GLAND  577 

The  presence  of  an  accessor)'  tliyroid  explains  ihe  absence  of  myxede- 
ma in  some  cases  of  comjjlete  thyroidectomy.  The  occurrence  of  a 
non-intlammalory  tumor  along  the  course  of  the  thyroglossal  duct, 
particuhirly  in  a  woman,  should  always  make  one  think  of  the  possi- 
bility of  an  accessor)'  thyroid. 

Ai)sence  or  deficiency  of  the  internal  secretion,  the  result  of 
atrophy  or  absence  of  the  thyroid,  causes  a  peculiar  group  of  symp- 
toms, which  is  called  cretinism  when  developing  soon  after  birth, 
myxedema  when  occurring  in  adults,  and  cachexia  strumpriva  when 
following  extirpation  of  the  gland.  The  essential  features  of  these 
conditions  are  a  non-pitting  edema  of  the  subcutaneous  tissues,  due 
to  infiltration  with  a  mucin-like  substance  (myxedema),  pallor  and 
dryness  of  the  skin,  loss  of  hair,  and  in  children  dwarfing  of  the  body 
and  idiocy,  and  in  adults  marked  impairment  of  the  intellectual 
faculties  and  loss  of  sexual  power.  According  to  Kocher  the  coagula- 
bility of  the  blood  is  increased  in  hypothyroidism.  The  treatment 
is  thyroid  extract,  one  grain  three  times  a  day,  gradually  increased 
to  10  or  more  grains,  watching  for  symptoms  of  thyroidism,  i.e., 
tachycardia,  nervousness,  delirium,  etc.  When  cure  has  been 
effected,  it  will  usually  be  necessary  to  administer  small  doses,  per- 
haps for  the  rest  of  the  patient's  life. 

Congestion  of  the  thyroid,  evidenced  by  slight  enlargement,  may 
be  due  to  cardiac  disease,  obstruction  to  the  veins  in  the  mediasti- 
num, anemia,  overexertion,  or  emotion;  in  women  it  may  occur  at 
puberty,  or  during  pregnancy  or  menstruation.  No  surgical  treat- 
ment is  required. 

Thyroiditis  is  usually  a  complication  of  one  of  the  acute  infectious 
diseases,  but  may  follow  injury.  In  addition  to  the  ordinary  signs 
of  inflammation  there  may  be  pressure  symptoms  much  like  those 
which  occur  in  ordinary  goiter.  Inflammation  of  a  goiter  is  called 
strumitis.  The  treatment  is  that  of  inflammation  elsewhere,  includ- 
ing incision  should  suppuration  occur.  Tracheotomy,  preceded  by 
division  of  the  isthmus  or  in  some  cases  extirpation  of  the  organ,  may 
be  required  if  breathing  is  seriously  embarrassed. 

Tuberculosis,  gummata,  actinomycosis,  and  hydatid  cysts  are 
treated  as  are  such  conditions  elsewhere. 

Tumors  of  the  thyroid  are  sometimes  called  malignant  goiters, 
and  indeed  it  is  often  difficult  to  make  a  sharp  distinction  between 
certain  goiters  and  some  neoplasms.  An  adenoma  theoretically  is 
is  distinguished  from  an  adenomatous  goiter  by  its  typical  micro- 
scopic picture,  and  by  the  fact  that  the  tumor  is  circumscribed  and 
separated  from  the  healthy  gland  tissue.  It,  however,  together 
37  j 


78 


MANUAL    OF    SURGERY 


with  carcinoma  and  sarcoma  (Fig.  285).  may  give  rise  to  metastases, 
hence  all  tumors  of  the  thyroid  gland  shold  be  regarded  as  mahgnant 
and  be  extirpated  at  the  earliest  possible  moment.  They  usually 
develop  after  forty,  often  from  a  simple  goiter,  are  hard,  fixed,  and 
irregular  in  contour,  grow  rapidly,  quickly  produce  pressure  symp- 
toms, and  often  come  under  observation  only  when  they  have  in- 
vaded surrounding  tissues  and  are  inoperable.  If  the  entire  gland 
is  removed,  the  patient  should  be  fed  on  thyroid  extract  subsequent 
to  operation.  In  the  later  stages  of  inoperable  growths  it  may  be 
necessary,  in  order  to  prevent  death  by  suffocation,  to  perform  trache- 
otomy, a  most  difficult  and 
dangerous  procedure  under  the 
circumstances,  as  one  must 
quickly  remove  sufficient  of  the 
tumor  tp  expose  the  trachea  be- 
fore it  can  be  opened  and  a  tube 
introduced,  and  even  then  it 
may  be  found  that  the  site  of 
the  compression  is  retrosternal, 
in  which  event  a  long  flexible 
tracheotomy  tube  must  be  in- 
troduced, or.  if  this  is  not  at 
hand,  a  flexible  catheter. 

Goiter,  struma,  or  broncho - 
cele  is  a  h}'perplasia  of  the 
thyroid  gland  not  of  infectious 
or  neoplastic  origin.  The  dis- 
ease may  involve  any  part  or 
all  of  the  gland,  but  is  most 
common  in  the  right  lobe,  and 


-Sarcoma  of  the   thyroid  gland. 
Note  enlarged  veins. 


Fig.  28, 

Note  enlarged  veins.  ^kjxx±xi.i^. 

occurs  more  frequently  m 
females,  usually  after  the  tenth  year.  The  cause  is  not  known.  The 
theory  that  it  is  due  to  magnesium  or  calcium  salts  or  some  other 
substance  in  the  drinking  water  probably  has  the  most  advocates. 
It  occurs  sporadically  in  all  parts  of  the  world,  and  is  endemic  in 
Central  Asia.  Switzerland  and  the  contiguous  portions  of  France. 
Italy,  Austria,  and  Germany;  in  England  it  has  been  called  Derby- 
shire neck  owing  to  its  prevalence  in  that  locahty;  in  this  country 
it  is  most  common  in  certain  parts  of  ^Michigan  and  in  the  mount- 
ainous regions  of  Pennsylvania. 

The  varieties  of  goiter  are:  i.  The  parencliymatous,  in  which  the 
whole  gland  is  involved,  although  one  lobe  may  be  larger  than  the 


1:AR,    NKCK,    TllVROII)    (W.AM) 


579 


other.  The  swelling;  is  soft,  elastic,  and  painless.  When  there  is 
an  excessive  development  of  the  stroma,  the  gland  is  harder  and 
perhaps  lobulated  (Jibrons  goilcr) ;  when  the  connective  tissue  is  small 
in  amount  and  the  acini  arc  distended  with  colloid  material,  the 
gland  is  softer  {follicular  or  colloid  goiter).  Cystic  goiter  is  due  to 
the  confluence  of  the  acini.  The  cysts  may  be  single,  or  multiple, 
vary  greatly  in  size,  and  contain  a  colloid  or  serous  material,  which 
may  be  brown  or  black  from  the  presence  of  altered  blood.  In- 
tracystic  papillomata  are  sometimes  found.  3.  Adenomatous 
goiter  (Fig.  286)  resembles  an  adenoma  in  structure;  it  may  develop 
in  one  portion  of  a  normal  gland  and  subsequently  involve  the 
whole  thyroid,  or  it  may  be  a  secondary  change  in  a  parenchymatous 
goiter,  and  not  infrequently  it  is  followed  by  the  formation  of  cysts. 
A  sharp  distinction  cannot  be  made  between  adenomatous  goiter 
and  adenoma  of  the  thyroid. 
4.  Exophthalmic  goiter  is  des- 
cribed below.  In  any  of  these 
varieties  certain  secondary 
changes  may  occur,  e.g.,  in- 
flammation, abscess,  hemor- 
rhage into  the  gland,  calcifica- 
tion, or  malignant  disease,  and 
in  any  there  may  be  enlarge- 
ment of  the  thymus  gland. 
Carinoma  occurs  most  fre- 
quently in  the  adenomas,  and 
is  to  be  suspected  when  a  nodular  goiter  rapidly  increases  in  size. 
The  exopthalmic  type  rarely  shows  malignant  change.  Simmons 
found  thymic  hyperplasia  in  less  than  one-half  of  the  cases  of  ordi- 
nary goiter,  and  in  three-fourths  of  the  cases  of  exophthalmic  goiter. 
Kocher  states,  however,  that  in  5740  operations  for  ordinary  goiter 
he  saw  not  one  thymic  hyperplasia,  and  not  one  patient  died  from 
status  lymphaticus. 

The  S)niiptoms  are  (i)  the  presence  of  a  tumor,  (2)  evidences  of 
pressure  and  (3)  signs  of  excess  or  deficiency  of  the  thyroid  secretion. 
I.  The  tumor  in  horseshoe-shaped  or  oval,  varies  greatly  in  size, 
sometimes  being  as  large  as  a  man's  head,  develops  insidiously, 
rises  and  falls  during  swallowing,  is  painless,  and,  excepting  the 
trachea,  is  not  adherent  to  the  surrounding  tissues.  Inflamed, 
malignant,  and  very  large  goiter,  however,  may  not  move  with 
deglutition,  and  other  cervical  swellings,  e.g.,  thyroglossal  cysts, 
subhyoid    bursa?,    and    abscesses,    lymph    glands,    and    malignant 


Fig.   286. — Adenomatous  goiter. 


580  MANUAL    OF    SURGERY 

growths  that  are  adherent  to  the  larynx,  trachea,  or  esophagus,  may 
move  with  deglutition.  2.  The  pressure  symptoms  depend  upon 
the  situation  of  the  growth,  thus  a  retrosternal  goiter  quickly 
produces  symptoms,  and  they  may  be  absent  in  even  the  largest 
goiters.  The  larynx  and  trachea  may  be  pushed  from  the  middle 
line,  or  the  latter  may  be  flattened  from  side  to  side,  causing  dyspnea 
and  cough  if  both  lobes  are  equally  enlarged.  Pressure  on  the 
esophagus  causes  dysphagia;  on  the  vessels  of  the  neck  headache, 
flushing  of  the  face,  and  epistaxis;  on  the  recurrent  laryngeal  nerve 
alteration  in  the  voice  or,  if  both  are  involved,  bilateral  paralysis  of 
the  muscles  of  the  larynx  and  death  (Mayo  states  that  in  one  fifth  of 
all  cases  of  goitre  there  is  paresis  or  paralysis  of  one  or  both  cords) ; 
on  the  pneumogastric  alteration  of  the  heart's  action;  and  on  the 
sympathetic  dilatation  of  the  pupil,  etc.  (chap.  xvii).  3.  Signs 
of  excess  or  deficiency  of  the  thyroid  secretion  also  may  be  encountered ; 
the  former  are  given  under  exophthalmic  goiter,  the  latter  under 
absence  of  the  thyroid. 

The  treatment  in  the  early  stages  may  be  medical,  viz.,  iodid  of 
potassium  internally,  and  red  oxid  of  mercury  ointment  or  iodin 
locally.  Thyroid  extract  is  of  value,  particularly  if  there  are  any 
signs  of  myxedema.  Electrolysis  and  radiotherapy  have  tem- 
porarily benefited  a  few  cases.  Medical  treatment  is  of  most  value 
in  parenchymatous  goiter.  If  the  goiter  increases  in  size  or  there 
are  pressure  symptoms,  operation  is  indicated.  Before  operation 
the  larynx  should  be  examined,  to  determine  the  condition  of  the 
vocal  cords,  and  if  there  is  any  suspicion  of  an  intrathoracic  growth 
or  if  one  is  not  sure  of  the  position  of  the  trachea  a  skiagram  should 
be  made.  Ligation  of  the  thyroid  arteries,  and  exothyreopexy,  i.e., 
drawing  the  thyroid  into  a  wound  in  the  neck  so  that  it  may  atrophy, 
have  been  employed,  while  as  a  palliative  or  emergency  operation 
in  cases  of  severe  dyspnea,  the  ribbon  muscles  of  the  neck  or  the 
isthmus  of  the  gland  have  been  divided.  The  usual  operations  are 
intraglandular  eniilceation,  which  is  indicated  in  a  localized  adenoma 
or  a  single  cyst,  or  in  a  small  collection  of  cysts,  and  partial  excision, 
or  thyroidectomy,  which  is  indicated  in  all  other  varieties,  care  being 
taken  to  leave  at  least  one-fourth  of  the  gland  in  order  to  prevent 
myxedema.  Local  anesthesia  is  strongly  recommended  by  many 
surgeons,  in  order  to  prevent  the  congestion  of  the  neck  incident  to 
ether  and  chloroform,  to  avoid  postoperative  vomiting,  which  may 
start  bleeding,  and  in  order  to  have  the  patient  speak  during  the 
operation,  so  that  the  surgeon  may  know  when  he  is  in  the  vicinity 
of  the  recurrent  laryngeal  nerve.     We  prefer  ether,  administered 


EAR,    NECK,    TUVROll)    (ILAND  581 

by  iiUralraclu'al  iiisuftlalion.  'I'lu"  i)])C'ralive  field  is  made  prominent 
1)V  placing  a  sand  i)ill()\v  under  the  neck,  and,  in  order  to  lessen 
bleeding,  the  uiii)er  i)ortion  of  the  body  is  elevated  (reversed  Tren- 
delenburg posture). 

Intraglandular  enucleation  is  ])erformed  by  exposing  the  gland 
by  a  transverse  or  oblique  incision,  incising  the  gland  down  to  the 
tumor,  and  shelling  out  the  tumor  with  the  fmgers  or  a  director; 
the  wound  is  then  quickly  j^acked  with  gauze  because  of  the  free 
bleeding,  and  as  the  gauze  is  gradually  removed,  the  bleeding 
points  are  ligated  or  surrounded  by  sutures.  The  cavity  is  closed 
by  catgut  sutures  and  the  skin  approximated,  leaving  space  for  a 
gauze  drain  for  twenty-four  hours. 

Partial  thyroidectomy  usually  means  removal  of  one  lobe.  A 
curved  transverse  incision,  with  the  concavity  upwards,  is  made 
over  the  tumor  from  the  outer  border  of  one  sternomastoid  to  beyond 
the  middle  line,  the  skin  and  platysma  divided,  the  ribbon  muscles 
separated  in  the  median  line  or  divided  transversely,  and  the  tibrous 
capsule  opened.  The  fibrous,  or  surgical  capsule,  lines  the  cavity  in 
which  the  thyroid  lies,  and  is  separated  from  the  true,  or  glandular 
capsule,  by  loose  areolar  tissue.  All  bleeding  is  checked,  the  lobe 
dislocated  from  its  fibrous  envelope,  the  superior  thyroid  vessels 
divided  between  two  ligatures,  and  the  inferior  thyroid  vessels 
tied  close  to  the  gland  in  order  to  avoid  the  recurrent  laryngeal  nerve. 
The  thyroidea  ima  if  present  also  is  tied.  The  parathyroids  are 
avoided  by  tying  all  vessels  close  to  the  true  capsule,  or,  as  suggested 
by  Mayo,  leaving  that  portion  which  covers  the  posterior  surface 
of  the  gland.  The  isthmus  of  the  gland  is  crushed  with  strong 
forceps  and  ligated  in  sections,  or  it  may  be  divided  and  the  bleeding 
controlled  with  sutures.  Any  attachments  to  the  cricoid  are 
separated,  or  perhaps  better,  a  thin  slice  of  the  gland  is  left  in  place 
in  this  situation  to  avoid  injury  to  the  recurrent  laryngeal  nerve. 
The  wound  is  irrigated  with  salt  solution,  the  remaining  portions  of 
the  gland  should  be  oversewn  with  catgut  to  further  insure  hem- 
ostasis,  and  closed  after  suturing  the  divided  muscles,  a  small  space 
being  left  for  drainage  with  silk  worm  gut  strands  for  twenty-four 
hours.  The  normal  anatomy  is  necessarily  disturbed  in  large 
growths;  thus  the  jugular  vein,  which  has  branches  coming  from 
the  tumor,  moves  forward  with  the  growth,  while  the  artery,  which 
has  no  such  connections,  is  pushed  backwards  and  outwards  and  may 
lie  external  to  the  vein.  The  tracheal  rings  may  be  absorbed  or 
softened,  hence  more  easily  injured;  in  some  cases  the  trachea 
collapses  as  soon  as  the  support  of  the  tumor  is  removed,  the  patient 


582  MANUAL    OF    SUKGEKY 

dying  of  asphyxia  unless  a  tube  is  inserted.  Sudden  death  may 
occur  also  from  reflex  inhibition  of  the  heart,  the  status  lymphaticus 
or  from  the  absorption  of  thyroid  secretion  from  the  wound.  It 
is  necessary  to  gently  handle  the  gland  to  avoid  squeezing  its  toxic 
secretion  into  the  circulation.  In  other  cases  thyroid  intoxication 
will  cause  high  fever,  rapid  pulse,  and  dyspnea  subsequently  to 
operation.  If  too  much  of  the  gland  is  removed,  myxedema  may 
follow;  and  if  the  parathyroids  are  excised  tetany  develops. 
Kocher's  mortality  in  over  5000  cases  is  less  than  i  per  cent. 

Exophthalmic  goiter  (Graves'  disease,  Basedow's  disease)  is  of 
unknown  origin.  Ninety  per  cent,  of  the  cases  are  females,  gen- 
erally between  the  ages  of  fifteen  and  thirty.  It  may  follow  severe 
emotional  storms,  overwork,  worry,  pregnancy,  or  ordinary  goiter 
{Basedowified  goiter).  Microscopic  examination  shows  a  marked 
increase  in  the  epithelial  elements  and  little  or  no  colloid  material. 
Judging  from  the  results  of  operative  treatment  the  chnical  pheno- 
mena are  due  to  derangement  of  the  sympathetic  nervous  system, 
in  consequence  of  excessive  thyroid  secretion,  or  of  some  toxin  in 
the  blood  which,  under  normal  conditions,  the  thyroid  gland 
destroys.  Thus  the  exophthalmos,  long  thought  to  be  due  to  an 
increase  in  the  orbital  fat,  is,  according  to  Landstrom,  the  result 
of  stimulation  of  the  cervical  sympathetic,  which  presides  over 
Miiller's  muscle,  and  a  film  of  muscular  tissue  passing  around  the 
eyeball  from  the  fascia  behind  to  the  lids  and  anterior  orbital  fascia. 
These  muscular  fibres  pull  the  eye  forwards  and  the  lids  backwards, 
serving  normally  to  antagonize  the  four  orbital  muscles,  which 
tend  to  draw  the  eye  backwards.  Recent  investigations,  however, 
seem  to  indicate  that  Graves'  disease  is  only  one  of  the  numerous 
manifestations  of  incoordination  between  the  various  ductless 
glands.  Of  particular  interest  at  the  present  time  is  the  relationship 
between  goiter  and  hyperplasia  of  the  thymus.  "No  Basedow 
without  thymus"  is  the  opinion  of  Klose.  Kocher  says  that  in 
61.2  per  cent,  of  the  cases  of  exopthalmic  goiter  coming  to  autopsy 
there  is  some  increase  in  the  parenchyma  of  the  thymus,  but  that 
clinically  only  30  per  cent,  show  enlargement,  the  greatest  number 
being  in  the  first  two  decades,  while  exophthalmic  goiter  is  most 
frequent  in  the  second  and  the  third  decades.  The  cardinal  sym- 
ptoms are  the  presence  of  a  goiter,  in  the  capsule  of  which  are  numer- 
ous large  vessels,  hence  pulsation,  thrill,  and  bruit  are  commonly 
found;  exophthalmos,  causing  a  widening  of  the  palpebral  fissure 
with  frequent  and  incomplete  winking  (Stellwag's  sign),  retardation 
of  the  movement  of  the  upper  lid  when  the  eyeball  is  rotated  down- 


EAR,    NECK,     IIIYKOII)    GLAND  583 

wards  (\()n  (iraofe's  sign),  and  inahilily  to  maintain  the  eyes  in 
convergence  (Mcebius's  sign);  lacliycardia,  often  with  palpitation 
and  dysjmca;  and  a  line  tremor.  In  the  later  stages  the  cardiac 
muscle  degenerates  and  permanent  dilatation  ensues  (goiter  heart). 
Sometimes  scleroderma  or  symmetrical  lipomata  develop,  and 
many  cases  terminate  in  myxedema.  Numerous  other  symptoms 
referable  to  the  nervous  system,  the  cardio-vascular  apparatus,  the 
gastrointestinal  tract,  or  the  anemia,  are  described,  e.g.,  irritability, 
attacks  of  mania,  prostration,  flushing  of  the  face,  excessive  sw.eating, 
throbbing  of  the  arteries,  capillary  pulse,  indigestion,  diarrhea, 
glycosuria.  Kocher  says  there  is  leukopenia,  particularly  of  the 
polymorphonuclears,  lymphocytosis,  and  diminution  in  the  coagu- 
lability of  the  blood.  Halstead  ascribes  the  lymphocytosis  to  the 
thymic  hyperplasia.  The  diagnosis  is  never  difficult,  except  in 
the  form  fruste,  in  which  the  goiter  or  the  exophthalmos,  or  both, 
may  be  absent.  Many  of  these  cases  are  incorrectly  diagnosticated 
hysteria  or  neurasthenia. 

The  treatment  in  the  beginning  is  medical.  Absolute  rest,  cardiac 
sedatives,  an  ice  bag  to  the  heart,  ergot,  belladonna,  phosphate  of 
soda,  and  extract  of  the  thymus,  pituitary,  spleen,  pancreas,  or 
suprarenals  are  recommended.  Thymus  therapy  benefits  50  per 
cent,  of  the  patients,  causes  an  increase  in  the  cardiac  symptoms  in 
10  per  cent.  (Kocher).  Electrolysis  and  the  radiotherapy  have 
been  employed.  Recently  encouraging  result  have  been  obtained 
with  a  serum  obtained  from  animals  injected  with  increasing  doses 
of  human  thyroid  extract.  Iodides,  thyroid  extract,  and  the  in- 
jection of  various  medicaments  into  the  gland  are  contraindicated. 
As  soon  as  medical  treatment  has  failed,  i.e.,  after  a  few  months, 
operation  should  be  proposed  before  the  condition  of  the  patient 
has  markedly  deteriorated.  Ligation  of  the  thyroid  vessels  (usually 
the  superior  including  the  upper  pole  of  the  gland)  may  be  indicated 
in  mild  cases,  as  a  preliminary  operation  to  thyroidectomy  in  severe 
cases,  and  as  an  auxihary  procedure  to  excision  of  one  lobe,  the 
vessels  of  the  other  lobe  being  tied.  Partial  thyroidectomy  is  the 
operation  of  choice.  The  average  results  are  "71  per  cent,  cured; 
9.6  per  cent,  improved;  6.4  per  cent,  unimproved,  failures,  lost  sight 
of,  or  partly  benefited;  and  12.6  per  cent,  died  (Hartley). 
Kocher 's  mortahty  in  535  cases  is  5.1  per  cent,  but  he  refuses  to 
operate  upon  "bad  risks."  The  dangers  have  been  mentioned 
under  partial  thyroidectomy.  Improvement  is  immediate,  but  the 
exopthalmos  may  persist  for  months,  and  recurrences  have  been 
noticed  in  a  few  instances.     Bilateral  resection  of  the  cervical  sym- 


584  MANUAL   OF    SURGERY 

pathetic  ganglia  (see  cervical  sympathetic  nerves,  chapter  xvii, 
page  256  gives  less  favorable  statistics,  but  may  be  indicated  in 
Graves'  disease  without  goiter,  or  combined  with  thyroidectomy, 
in  cases  in  which  the  ophthalmic  symptoms  predominate.  Thymec- 
tomy, without  removal  of  the  thyroid,  has  been  performed  for 
Graves'  disease  by  a  few  surgeons.  The  thymus  should  certainly 
be  sought  during  thyroidectomy,  and  if  enlarged  removed.  The 
other  operations  mentioned  under  the  treatment  of  goiter  also  have 
been  employed  for  Graves'  disease. 

The  thymus  gland  usually  begins  to  shrink  at  the  end  of  the 
second  year  and  at  the  time  of  puberty  can  no  longer  be  found. 
When  it  persists  and  enlarges  pressure  may  be  exerted  on  the  trachea, 
the  great  blood  vessels,  or  on  the  left  pneumogastric  or  its  recurrent 
branch.  Hyperplasia,  or  hypertrophy,  as  it  is  sometimes  called, 
may  be  an  independent  affection,  rarely  occurring  except  in  infants, 
or  it  may  be  associated  with  leukemia,  Hodgkin's  disease,  ordinary 
goiter,  exophthalmic  goiter,  or  the  status  lymphaticus.  Clinically 
the  pressure  effects  are  continuous  or  intermittent. 

In  the  continuous  form  (thytnic  stenosis  of  the  trachea)  there  is 
progressive  dyspnea,  with  stridor  and  crises  of  suffocation.  The 
dyspnea  is  chiefly  expiratory,  as  the  gland  is  drawn  down  into  the 
mediastinum  during  inspiration,  thus  freeing  the  air  passages 
The  diagnosis  is  made  by  feeling  a  tumor  mounting  in  the  episternal 
notch  during  expiration  and  disappearing  during  inspiration,  by 
dulness  on  percussion  over  the  manubrium,  by  the  associated 
lymphocytosis,  and  by  the  X-ray,  all  of  which  signs,  however,  may 
be  present  when  the  trouble  is  due  to  enlarged  mediastinal  lymph 
glands.  In  one  case  of  enlarged  thymus  Jackson  demonstrated  the 
stenosis  by  bronchoscopy. 

In  the  intermittent  form  (thymic  asthma)  the  attack  appears 
suddenly,  possibly  as  the  result  of  extension  of  the  head  or  venous 
engorgement  of  the  gland.  Death  occurs  within  a  few  minutes,  or 
the  infant  recovers,  only  to  suffer  from  subsequent  paroxysms 
which  become  more  and  more  frequent. 

The  treatment  of  thymic  stenosis  of  the  trachea  and  thymic 
asthma  is  exothymopexy  (i.e.,  drawing  the  gland  up  over  the  sternum 
and  securing  it  with  sutures)  or,  better,  subcapsular  enucleation, 
after  making  a  median  incision  just  above  the  manubrium.  Olivier 
(191 2)  has  collected  42  cases  ot  thymectomy,  with  15  deaths. 
Radiotherapy  may  possibly  be  of  service  in  cases  not  suited  for 
operation. 

The  carotid  gland  or  body,  when  present,  is  attached  to   the 


EAR,    NECK.    TllVkoll)    (.LAM)  585 

cart)ti(l  sheath  al  or  near  the  Ijifurcalion  of  the  artery.  It  is  about 
the  size  ol  a  <j;rain  oi  corn  and  is  composed  chiefly  ot  endothelial 
cells.  Its  nature  is  unknown.  Callison  and  Mackenty  have 
collected  sixty  endotheliomata  or  peritheliomata  arising  from  this 
gland.  These  "potato  tumors  of  the  neck"  are  located  at  the 
bifurcation  of  the  carotid  under  the  sternomastoid,  are  slightly 
movable  transversely  but  not  vertically,  transmit  pulsation,  thrill 
and  bruit  from  the  carotid  artery,  and  often  exist  for  a  number  of 
years  before  taking  on  malignant  features,  when  there  is  involvement 
of  the  vagus  (with  its  recurrent  branch)  and  of  other  nerves. 
Carotid  tumors  should  be  extirpated,  an  operation  which  will 
sometimes  necessitate  excision  of  the  carotid  artery.  Of  fifty-four 
patients  operated  upon,  twelve  died;  recurrence  occurred   in  eight. 


CHAPTER  XXIV 

RESPIRATORY  SYSTEM 

THE  NOSE 

Rhinoscleroma  is  a  very  rare  infectious  disease  due  to  the  bacillus 
of  rhinoscleroma.  A  number  of  hard  nodules,  or  a  still  infiltration, 
forms  about  the  nostrils  and  sometimes  about  the  lips,  or  in  the 
mucous  membrane  of  the  mouth,  pharynx,  or  larynx.  The  disease 
is  painless,  may  last  for  years,  and  ultimately  leads  to  stenosis.  In 
the  early  stages  recovery  may  follow  excision.  Later,  treatment  is 
futile. 

Rhinophyma  is  a  hypertrophic  form  of  acne  rosacea  in  which  red 
greasy  masses  form  on  the  lower  end  of  the 
nose,  producing  a  deformity  which  has  been 
called  hammer  nose  (Fig.  287).  It  may  be 
treated  by  excision  with  subsequent  skin 
grafting. 

Deformities  of  the  nose  may  be  congenital, 
or  result  from  injury,  destructive  diseases,  or 
operations,  e.g.,  for  the  removal  of  malignant 
disease.     All  operative  efforts  to  rebuild  a  de- 
FiG.  287.— Rhinophyma,    formed  uosc  are  included  under  the  term  rhino- 

treated  by  excision.  ,  i  •    i  .    i 

plasty,  which  may  be  partial  or  complete,  ac- 
cording to  its  extent. 

Deformity  of  the  Roman  nose  type  is  corrected  by  making  a 
small  longitudinal  incision  in  the  middle  line  of  the  nose,  and  remov- 
ing the  redundant  tissue  with  a  chisel,  if  bone,  or  a  knife,  if  cartilage. 
The  wound  is  then  sutured.  Expansion  of  the  bridge,  or  frog  nose, 
is  commonly  caused  by  intranasal  growths,  and  the  treatment  is 
directed  to  the  cause.  A  tuberous  nose  is  treated  by  removing  a 
wedge-shaped  section. 

Clefts  of  the  nose  are  remedied  by  sutures  after  freshing  the 
edges.  Figs.  290  to  293  also  illustrate  the  repair  of  a  lateral  defect. 
Figs.  294  to  299  illustrate  methods  of  constructing  a  columna  nasi. 
The  necessary  rigidity  can  be  obtained  by  implanting  a  piece  of 
cartilage  or  bone.  Saddle  nose  rtiay  be  caused  by  injury,  but  is 
most  frequently  the  result  of  SN-philitic  ulceration  of  the  septum. 


RESPIRATORY    SYSTEM 


587 


\'arious  more  t)r  less  unsatisfactory  procedures  have  been  devised 
lor   this  deformity.     Artificial   ]jri(lii;es  of  celluloid,  rubber,  silver. 


Fig.  288.  Pig.  289. 

Figs.  288  and  289. — Operations  for  clett  nose.      (Esmarch  and  Kowalzig.) 

gold,  etc.,  or-a  free  transplant  of  bone  (rib,  anterior  surface  of  the 
tibia),    costal  cartilage,  or  fat  may  be  inserted  beneath  the  skin 


Fig.  290.  Fig.  291.  Pig.  292.  Fig.  293. 

Figs.   290  to  293. — Operations  for  lateral  defect  of  the  nose.      (Esmarcti  and  Kowalzig. j 

through   an   external  incision  or  from  within  the  nose.     In  some 
cases    the   nasal   bones   have   been  broken  or  chiseled  from  their 


Fig.   294.  Pig.  295.  Pig.  296. 

Figs.   294  to  296. — Methods  of  constructing  the  columna  nasi.      (Esmarch  and   Ko- 
walzig.) 

attachments,  and  held  in  an  elevated  position  by  a  spectacle  clip,  or 
by  pins  inserted  beneath  them.  A  transverse  incision  may  be  made 
across   the  sunken  part  of  the  nose,  thus  allowing  the  tip  to  be 


588 


MANUAL    OF    SURGERY 


pulled  down.  The  resulting  gap  is  closed  by  a  flap  turned  inward 
from  each  cheek,  the  skin  surface  facing  the  nasal  cavity.  A  flap 
from  the  forehead  is  brought  down  to  cover  the  raw  surfaces  of  the 
cheek  flaps,  and  the  wounds  in  the  forehead  and  cheeks  sutured. 
The  subcutaneous  injection  of  sterile  paraftin  has  been  used  with 
some  success  in  this  deformity.     The  skin  of  the  nose  should  be 


Fig.   297.  Fi«^-   ^^8.  Fig.   299. 

Figs.   297  to  299. — Methods  of  constructing  the  columna  nasi.      (Esmarch  and  Ko- 

walzig.) 

loose,  and  the  melting  point  of  the  parafiin  (mixed  with  liquid 
parafhn  or  vaselin)  above  ii5°F.  The  parafhn  is  melted,  injected 
by  a  screw  piston  syringe  in  a  semi-solid  state,  and  molded  with  the 
fingers.  The  complications  are  abscess,  glazing  and  thickening  of 
skin,  diffusion,  and  embolism. 


Fig.  300.  Fig.  301. 

Figs.  300  and  301. — Indian  method  of  rhinoplasty.      (Esmarch  and   Kowalzig.) 

Absence  of  the  nose  is  rarely  congenital ;  it  may  result  from  trau- 
matism, burns  or  gangrene  from  freezing,  but  is  most  frequently  due 
to  disease,  e.g.,  syphilis,  lupus,  and  malignant  growths.  Various 
methods  of  complete  rhinoplasty  have  been  used  with  more  or  less 
satisfaction.     When  an  operation  for  the  reproduction  of  the  nose  is 


RESPIRATORY    SYSTEM 


589 


(Iccnu'd   inadvisahlc,   an  artificial  nose  held   in  place  by  spectacle 
rims  may  he  worn.      Tlu'  hidiaii   method  for  complete  rhinoplasty 


Fig.  302. 


(Figs.  300,  301)  consists  in  supplying  the  defect  by  a  flap  from  the 
forehead.     Gilles  has  modified  the  method  by  the  use  of  cartilage 


590 


MANUAL    OF    SURGERY 


grafts   to   form   alas   and    columna  nasi.     (Fig.  302  and  303.)     A 
plaster  cast  of  the  face  is  taken  and  a  model  of  the  missing  part 


Fig.  303. 


made  on  the  cast  with  plastacine.     On  this  completed  model,  the 
necessary  cartilage  supports  are  outlined,  the  skin  flaps  measured 


RESPIRATORY    SVSTKM 


591 


and  cut  out  of  wash  leather,  and  from  tliese  tin  foil  patterns  are 
made,  which  ])ermit  of  sterihzation.  A  piece  of  cartila<ie  is  removed 
from  the  ribs,  shaped  according  to  the  patterns  obtained  from  the 
model  and  embedded,  under  the  skin  of  the  forehead  if  the  bridge 
is  lacking,  under  the  skin  covering  the  bridge  if  this  has  not  been 
destroyed  and  in  the  proper  positions  under  the  skin  of  the  cheek 
{or  the  formation  of  the  alai  when  turned  hinge  fashion  to  meet  the 
tip  of  the  septal  transplant.  The  second  stage,  after  the  transplants 
have  become  fixed,  consists  in  turning  down,  hinge  wise,  the  septal 
graft  and  turning  up,  the  alar  graft  to  meet  at  a  point  which  will 
be  the  tip  of  the  new  nose.  From  the  tin  foil  patterns  the  pedicled 
forehead  skin  flap  is  outhned  (which  should  contain  a  branch  of 
the  supra  orbital  or  supra  temporal  arteries),  reflected  downward 


Fig.   304. — Italian  method  of  rhinoplasty.    Fig.   305. — French  method  of  rhinoplasty. 
(Monod  and  Vanverts.)  (Monod  and  Vanverts.) 

and  accurately  sutured  in  place.  When  a  long  pedicle  is  necessary, 
its  skin  edges,  at  the  bridge,  are  approximated  with  sutures,  thus 
forming  a  tube  of  skin  and  obliterating  the  raw  granulating  surface 
on  the  under  side  of  the  pedicle,  and  diminishing  the  possibilities  of 
infection.  When  the  pedicle  is  cut  in  2-3  weeks,  it  is  reopened  and 
replaced  in  the  defect  in  the  forehead.  (Fig.  303.)  The  ItaHan  and 
French  methods  do  not  give  an  epitheHal  lining  to  the  nose.  In  the 
Italian  method  the  flap  is  taken  from  the  arm  (Fig.  304) ,  which  must 
be  fixed  by  a  suitable  apparatus  until  union  has  occurred;  the  pedicle 
is  then  divided,  and  the  alae  and  septum  formed  from  the  lower 
portion  of  the  flap.  This  method  may  be  varied  by  taking  a  flap 
from  the  palm,  a  flap  consisting  of  soft  parts  and  a  piece  of  the  ulna 
from  the  inner  side  of  the  forearm,  or  a  flap  containing  a  pre\-iously 


592  MANUAL    OF    SURGERY 

transplanted  segment  of  bone  or  cartilage.  In  the  French  method 
(Fig.  305)  the  flaps  are  formed  from  the  cheeks.  Several  successful 
attempts  have  been  made  to  replace  the  bony  framework  of  the 
nose  by  suturing  the  freshened  end  of  a  finger  into  the  upper  angle 
of  the  nasal  defect,  and  when  union  has  occurred,  amputating  the 
finger.     The  proximal  phalanx  is  flexed  to  form  the  columna  nasi. 

Crooked  nose  may  be  congenital  or  traumatic,  and  is  usually 
associated  with  flexion  of  the  septum,  the  correction  of  which  may 
straighten  the  nose.  When  the  nasal  bones  themselves  are  deformed, 
they  may  be  molded  into  shape  after  separating  their  attachments 
with  a  chisel,  through  a  small  incision  at  the  root  of  the  nose. 

Deviation  of  the  septum  may  be  caused  by  injury  or  be  the  result 
of  defective  development.  The  deflection  may  be  vertical,  horizontal, 
or  oblique,  bowed  or  angular  and  the  septum  may  or  may  not  be 
thickened.  A  sigmoid  deviation  is  a  double  curve,  one  projecting 
into  each  nostril.  The  cartilaginous  septum  is  the  portion  usually 
involved.  The  condition  is  very  common,  but  in  the  slighter  forms 
gives  no  trouble.  In  more  marked  cases  there  may  be  stenosis  of 
one  nostril,  and  various  reflex  troubles,  such  as  are  to  be  mentioned 
under  polyps.  In  the  presence  of  direct  or  reflex  troubles  treatment 
will  be  required.  When  there  is  marked  thickening,  or  the  develop- 
ment of  cartilaginous  or  bony  spurs  of  the  septum,  these  should  be 
removed  with  knife  or  saw,  and  perhaps  no  further  treatment  will  be 
needed.  Warping  of  the  cartilage  itself  is  corrected  by  incisions 
along  the  lines  of  deviation,  in  order  to  lessen  the  resiliency  of  the 
septum.  These  incisions  may  be  made  by  introducing  a  sharp  knife 
beneath  the  mucous  membrane,  or  by  special  knives  or  punches, 
after  which  it  may  be  possible  to  correct  the  deformity  with  the 
fingers.  In  other  cases  septal  forceps  are  introduced,  one  blade  in 
each  nostril,  and  the  cartilage  broken  from  its  attachments  and 
straightened.  It  is  held  in  a  corrected  position  by  nasal  tampons  of 
gauze,  or  by  rubber  or  metal  splints.  The  tampons  are  removed 
and  the  nose  cleansed  daily  until  union  has  occurred.  Roberts  uses 
long  pins  such  as  have  been  described  under  fracture  of  the  nose. 

Epistaxis,  or  bleeding  from  the  nose,  may  be  traumatic,  e.g., 
from  blows,  fracture  of  the  skull,  picking  the  nose,  foreign  bodies, 
etc.,  or  it  may  be  spontaneous,  e.g.,  from  plethora,  ulcers,  tumors, 
rarefied  air,  vicarious  menstruation,  varicose  veins,  cardiac  or  pul- 
monary disease,  acute  diseases  (notably  typhoid),  and  diseases  in 
which  there  is  a  tendency  to  hemorrhage  (hemophilia,  scurvy,  pur- 
pura, etc.). 

The  treatment  is  removal  of  the  cause  if  possible.     When  depend- 


RESPIRATORY    SYSTEM 


593 


ing  upon  an  intracranial  congestion  epistaxis  may  l)c  beneficial,  and 
should  be  stopped  only  when  it  becomes  excessive.  The  head  should 
be  elevated,  constrictions  about  the  neck,  and  chest  removed,  and 
blowing  the  nose  forbidden.  Compression  of  the  nostrils  will  check 
the  bleeding  if  it  be  well  forward.  When  further  back,  the  bleeding 
point  may  be  detected  with  the  speculum  and  head  mirror,  and 
touched  with  the  galvanocautery,  or  a  swab  soaked  in  chromic  acid 
solution.  Sprays  or  douches  of  ice  water,  adrenahn  solution, 
or  antipyrin,  5-10  per  cent.,  are  sometimes  efficient  and  do  not 
possess  the  disagreeable  features  of  other  styptics.  In  serious  cases, 
however,  the  nostrils  should  be  at  once  plugged  with  gauze  moistened 
with  adrenahn.  If  the  bleeding  comes  from  the  anterior  portion  of 
the  nasal  passages,  it  may  be  controlled  by  packing  through  the 


Fig.  306. — The  Bellocq  cannula.  A  concealed  watch  spring  with  a  ring  at  the  end 
through  which  the  silk  is  passed,  is  made  to  curl  forward  into  the  mouth  after  the 
cannula  is  in  position.     (Heath.) 

anterior  nares.  In  other  cases  it  will  be  necessary  to  plug  the  posterior 
nares  in  addition.  A  soft  catheter  with  a  long  piece  of  silk  passed 
through  the  eye  is  pushed  along  the  floor  of  the  nose  until  it  reaches 
the  pharynx,  when  the  silk  is  grasped  with  forceps  and  the  catheter 
withdrawn,  so  that  the  silk  passes  in  through  the  nose  and  out 
through  the  mouth.  Several  pieces  of  gauze,  gradually  increasing 
in  size,  are  fastened  to  the  middle  of  the  silk,  which  is  then  drawn 
out  through  the  nose  while  the  finger  guides  the  tampons  up  behind 
the  soft  palate.  The  ends  of  the  silk  are  now  tied  together  and  the 
anterior  nostrils  plugged.  After  a  day  or  two  the  posterior  pack 
may  be  removed  by  drawing  downward  on  the  string  through  the 
mouth,  and  the  nostrils  sprayed  with  a  mild  antiseptic  solution.  Fig. 
306  shows  a  Bellocq  cannula,  which  may  be  used  to  pass  the  silk 

38 


594  MANUAL    OF    SURGERY 

through  the  nose.  An  easy  and  sometimes  efficient  method  for 
making  pressure  within  the  nostril  is  to  fasten  a  condom  over  a 
rubber  catheter,  and  when  this  has  been  inserted,to  inflate  the  condom 
and  tie  the  catheter. 

Foreign  bodies  in  the  nose  are  most  frequent  in  children,  in  whom 
a  unilateral  purulent  discharge  should  always  suggest  such  an 
accident.  Among  other  symptoms  are  pain,  epistaxis,  and  stenosis. 
Removal  may  be  effected  by  forceps,  hook,  loop,  or  snare.  The 
forcible  injection  of  water  into  the  opposite  nostril  is  not  recom- 
mended. An  incrustation  of  salts  about  a  foreign  body  or  particle 
of  mucus  is  called  a  rhinoUth,  the  symptoms  and  treatment  of  which 
are  much  hke  those  of  foreign  body.  Parasites,  e.g.,  maggots,  may 
be  removed  from  the  nasal  cavity  by  douching  with  equal  parts 
of  chloroform  and  water. 

Tumors  of  the  nasal  cavities  include  many  different  forms,  both 
benign  and  malignant,  but  a  sufficiently  clear  idea  of  their  behavior 
and  treatment  may  be  obtained  from  a  short  description  of  the  two 
common  varieties,  viz.,  mucous  and  fibrous  polypi. 

Mucous,  or  m3^omatous  polypi,  most  frequently  arise  in  the 
neighborhood  of  the  middle  turbinate  bone,  often  as  the  result  of 
disease  of  the  accessory  sinuses.  Cystic,  adenomatous,  or  fibrous 
changes  may  occur.  They  are  movable,  almost  transparent,  and  of  a 
bluish  gray  color.  The  symptoms  are  a  mucopurulent  discharge, 
nasal  obstruction,  and  sometimes  epistaxis.  Cough,  asthma,  head- 
ache, facial  neuralgia,  asthenopia,  anemia,  possibly  epilepsy,  and 
other  reflex  symptoms  may  be  caused  by  polyps.  They  should 
be  removed  by  seizing  the  growth  with  forceps,  and  twisting  the 
pedicle  until  the  growth  is  loose,  or  by  a  wire  loop  or  ecraseur,  with 
which  the  pedicle  is  gradually  cut  through.  In  either  case  the  base 
should  be  cauterized  with  the  galvanocautery  or  some  chemical 
caustic. 

Fibrous  pol3rpi  are  much  more  serious  than  mucous  polyps,  as  they 
often  contain  sarcomatous  elements,  progress  steadily,  and  press  on 
adjacent  parts,  causing  exophthalmos,  disfigurement,  etc.  The 
so-called  nasopharyngeal  polyp  is  always  a  fibrosarcoma.  Fibromata 
when  small  may  be  removed  with  the  snare,  but  such  is  always 
attended  with  some  risk  of  hemorrhage.  When  of  large  size  a  very 
formidable  operation  may  be  needed,  such  as  resection  of  the  upper 
jaw  (temporary  or  permanent)  or  removal  of  a  portion  of  the  roof  of 
the  mouth.  For  anterior  grow^ths  sufficient  exposure  has  been 
obtained  by  incising  the  mucous  membrane  between  the  upper  lip 
and  the  jaw,  cutting  through  the  cartilages  of  the  nose,  and  tem- 


RESPIRATORY   SYSTEM  595 

porarily  displacing  the  entire  nose  upwards.  Temporary  osteo- 
plastic resections  of  the  nose  are  made  also  by  an  external  incision. 

Synechia,  or  adhesion  between  the  intranasal  structures,  may  be 
congenital,  but  is  usually  the  result  of  previous  ulceration.  Adhe- 
sions arc  most  frequent  in  narrow  noses,  and  interfere  with  respira- 
tion and  drainage.  They  are  treated  by  incision  or  excision,  the 
raw  surfaces  being  subsequently  separated  by  a  plug  of  rubber, 
metal,  or  cotton. 

Ozena  is  a  term  often  appHed  to  any  fetid  discharge  from  the 
nose,  but  it  should  be  restricted  to  cases  of  chronic  atrophic  rhinitis, 
a  condition  in  which  the  nasal  fossae  are  roomy,  the  mucous  mem- 
brane atrophic  and  covered  with  scabs,  and  in  which  there  is  a  very 
objectionable  odor,  not  appreciated  by  the  patient.  The  reader  is 
referred  to  special  text-books  for  a  full  consideration  of  this  affection 
and  its  treatment.  Other  causes  of  a  foul  discharge  from  the  nose 
are  tumors,  foreign  bodies,  rhinoliths,  ulcers  (syphilitic,  tuberculous, 
malignant,  simple),  disease  of  the  accessory  sinuses,  and  necrosis  of 
bone.  A  unilateral  discharge  in  children  is  most  frequently  caused 
by  a  foreign  body,  and  in  adults  by  disease  of  the  accessory  sinuses. 
The  diagnosis  requires  thorough  cleansing  of  the  nose,  and  careful 
examination  of  its  interior  with  the  speculum  and  head  mirror.  The 
treatment  varies  widely  with  the  cause,  and  may  involve  removal  of 
necrotic  bone  or  cartilage. 

Post-nasal  adenoids  is  a  term  applied  to  hyperplasia  of  the 
pharyngeal  lymphoid  tissue,  or,  as  it  is  sometimes  called,  the  pharyn- 
geal or  Luschka's  tonsil,  which  is  analogous  to  the  faucial  and  Ungual 
tonsils.  Adenoids  are  most  common  in  children  of  a  tuberculous 
tendency,  and  are  probably  the  result  of  repeated  catarrhal  inflam- 
mations. The  symptoms  are  mouth  breathing,  change  in  the  voice, 
headache,  snoring  during  sleep,  narrowing  of  the  nostrils,  and 
interference  with  nasal  respiration.  The  child  has  a  stupid  look  and 
indeed  the  mental  development  may  be  retarded.  There  may  be  a 
purulent,  discharge,  occasionally  mixed  with  blood,  from  the  nose  or 
pharynx,  and  deafness  or  middle  ear  disease  may  follow.  The 
palate  is  often  high,  the  upper  incisor  teeth  prominent,  and  the 
cervical  glands  enlarged.  There  may  be  impairment  of  taste  and 
smell,  and  later  in  life  deformity  of  the  chest,  the  ribs  being  sunken 
and  the  spine  kyphotic  because  of  interference  with  deep  inspiration. 
The  diagnosis  is  made  by  posterior  rhinoscopy,  or  better,  in  young 
children,  by  the  finger  passed  up  into  the  pharynx,  when  the  soft, 
easily  bleeding  mass  is  readily  detected. 

The  treatment  in  practically  all  cases  is  removal  by  operation. 


59^  MANUAL    OF    SURGER\' 

although  there  is  a  tendency  for  adenoids  to  decrease  in  size  or  dis- 
appear later  in  life.  The  patient  is  etherized  and  the  head  allowed 
to  hang  over  the  table.  Long  curved  forceps,  such  as  those  of 
Lowenberg,  are  passed  up  behind  the  soft  palate,  which  is  guarded 
with  the  left  index  finger,  and  the  greater  portion  of  the  mass  re- 
moved, care  being  taken  not  to  grasp  the  septum  or  include  the 
openings  of  the  Eustachian  tubes.  Any  fragments  which  remain 
may  be  removed  with  the  finger  nail  or  the  Gottstein  curette.  Bleed- 
ing is  very  profuse  but  soon  ceases. 

AFFECTIONS  OF  THE  SINUSES 

Frontal  Sinuses.- — Fracture  of  the  anterior  wall  is  common  and 
may  lead  to  emphysema  of  the  face  and  scalp,  or  in  compound  cases 
to  necrosis  of  the  bone.  If  there  is  much  depression  the  bone  may 
be  elevated  to  prevent  deformity,  opportunity  being  afforded  at  the 
same  time  to  make  sure  that  the  posterior  wall  is  not  injured.  In 
rare  cases  a  fistula  through  which  air  passes  may  follow.  Reference 
has  already  been  made  to  pneumatocele  (chap.  xxi).  Foreign 
bodies  introduced  from  without,  or  insects  which  have  ascended 
from  the  nose,  may  cause  empyema  of  the  sinus. 

Inflammation  may  be  caused  by  injuries,  foreign  bodies,  disease  of 
adjacent  bones,  syphilis,  or  tuberculosis,  but  is  usually  secondary  to 
rhinitis.  In  acute  simple  cases  there  is  frontal  headache  which  sub- 
sides with  the  acute  rhinitis.  If  the  nasofrontal  duct  (infundibulum) 
becomes  blocked,  the  sinus  distends  with  mucus  (hydrops,  or  muco- 
cele) or  pus  (empyema).  In  the  former  an  eiilargement  in  the  region 
of  the  sinus  is  noticed,  with  egg-shell  crackhng  in  the  later  stages 
owing  to  thinning  of  the  bone.  In  acute  empyema  there  may  be 
redness  and  edema  over  the  sinus  with  general  septic  symptoms. 
The  process  subsides  with  the  discharge  of  pus  from  the  nose,  or  it 
may  extend  and  involve  the  frontal  bone,  meninges,  brain,  or  intra- 
cranial venous  sinuses.  Chronic  empyema  is  characterized  by  pain, 
tenderness,  bulging  of  the  sinus,  pus  and  polypoid  granulations  in  the 
anterior  part  of  the  middle  meatus,  and  sometimes  by  disturbances 
of  vision  and  exophthalmos.  The  X-ray  shows  the  sinus  to  be 
enlarged  and  opaque;  the  latter  sign  may  be  demonstrated  also 
by  transillumination,  an  electric  lamp  being  held  in  the  angle  of  the 
orbit. 

The  treatment  of  acute  inflammation  is  that  of  the  accompanying 
rhinitis.  If  suppuration  occurs,  the  sinus  should  be  opened  through 
an  incision  from  the  root  of  the  nose  outwards  through  the  eyebrow 


RESPIRATORY    SYSTEM  597 

to  the  sii])ra(>rl)ital  notcli,  the  aiUcrior  wall  hcin*!;  ])erf()ratc(l  wilh  a 
trephine  or  tj;oii,u;<''  ji-'^l  bi'low  the  line  joininii;  the  two  suj)ra()rbital 
notches  and  a  little  away  Irom  the  median  line.  The  sinus  may  be 
curetted,  irrigated,  and  jxicked  with  gau/e.  so  that  it  may  ch)se  by 
granulations  and  shut  off  the  nasofrontal  duct,  or  it  may  be  neces- 
sary to  remove  the  entire  anterior  wall,  but  this  should  be  avoided 
whenever  possible,  owing  to  the  disfigurement.  Killian  removes  the 
anterior  wall  and  floor  of  the  sinus,  leaving  a  bridge  of  bone  at  the 
inner  angle  of  the  orbit  to  lessen  deformity.  Some  surgeons  push  a 
small  tube  into  the  nasofrontal  duct  in  order  to  drain  the  sinus  into 
the  nose,  and  then  close  the  skin  incision.  It  may  be  possible  for  a 
skilled  rhinologist  to  enter  the  infundibulum  from  the  nose  after 
removing  the  anterior  tip  of  the  middle  turbinate,  but  the  duct 
cannot  be  enlarged  without  great  danger,  so  that,  although  catheteri- 
zation may  be  useful  from  a  diagnostic  standpoint,  it  should  not  be 
used  as  a  means  of  treatment. 

Tumors,  both  benign  and  malignant,  may  arise  in  the  frontal 
sinus.  When  of  large  size,  they  may  press  on  the  brain  or  on  the 
eye,  causing  blindness  and  displacement  of  the  eyeball.  They 
should  be  excised. 

Ethmoiditis  may  cause  pain  and  tenderness  at  the  root  of  the  nose, 
disturbance  of  vision,  mental  hebetude,  anosmia,  and  possibly 
cellulitis  of  the  orbit,  meningitis,  or  abscess  of  the  brain.  There  may 
be  a  continuous  discharge  of  pus  from  the  nose  and  polypi  in  the 
middle  meatus.  Probing  reveals  necrotic  bone  and  opacity  can  be 
demonstrated  by  the  X-ray.  The  treatment  is  excision  of  the  anterior 
end  of  the  middle  turbinate,  to  permit  drainage  and  removal  of  the 
cells  by  curettage.  The  best  way  to  reach  the  ethmoid  cells  by  an 
external  incision  is  through  the  inner  wall  of  the  orbit,  and  such  is 
particularly  indicated  if  the  pus  has  perforated  in  this  direction. 

The  sphenoidal  sinuses  open  at  the  junction  of  the  roof  of  the 
nose  with  the  wall  of  the  nasopharynx,  and  this  opening  may  be  en- 
larged in  a  downward  and  outward  direction  in  cases  of  sphenoidal 
empyema.  Sphenoidal  and  ethmoidal  disease  are  commonly  asso- 
ciated, and  may  cause  meningitis,  abscess  of  the  brain,  or  thrombosis 
of  the  cavernous  sinus.  Pus  flows  into  the  superior  meatus,  necrotic 
bone  may  be  detected  with  the  probe,  and  the  X-ray  shows  abnormal 
density.  The  sinus  may  be  opened  through  the  posterior  ethmoidal 
cells  after  the  removal  of  the  middle  turbinate,  through  the  orbit  and 
posterior  ethmoidal  cells,  or  through  the  antrum  of  Highmore  and 
posterior  ethmoidal  cells. 

Empyema  of  the  antrum  of  Highmore  (the  maxillary  sinus)  is 


598  MANUAL    OF    SURGERY 

most  frequently  due  to  carious  teeth,  but  may  result  also  from  infec- 
tion of  the  nasal  cavities,  or  from  the  entrance  into  its  opening  of  pus 
from  the  frontal  or  ethmoidal  sinuses.  Injury  is  responsible  for 
a  small  number  of  cases.  The  symptoms  are  pain,  tenderness,  edema 
of  the  cheek,  and  an  intermittent  unilateral  discharge  of  pus  from  the 
middle  meatus,  most  marked  when  the  diseased  side  is  upward  or 
when  the  patient  bends  forwards,  and  is  accompanied  by  marked  sub- 
jective fetor.  If  the  opening  into  the  middle  meatus  is  obstructed, 
the  cavity  becomes  distended,  causing  in  extreme  cases  stenosis  of 
the  nostril,  exophthalmos,  depression  of  the  palate,  and  a  promi- 
nence beneath  the  malar  eminence  due  to  bulging  of  the  outer  wall, 
which  in  old  cases  may  crackle  under  the  finger.  Acute  cases  may 
be  associated  with  septic  constitutional  symptoms.  Percussion  over 
the  antrum  will  give  a  dull  instead  of  a  tympanitic  sound,  and  trans- 
illumination, by  placing  a  small  electric  light  in  the  patient's  mouth 
in  a  dark  room,  or  the  X-ray,  will  show  the  diseased  much  darker 
than  the  normal  side.  In  doubtful  cases  in  which  pus  cannot  be  seen 
coming  from  the  antral  opening,  an  exploratory  puncture  may  be 
made  in  the  inferior  meatus,  one  inch  behind  the  anterior  end  of  the 
inferior  turbinate,  or  if  the  nostril  is  blocked,  by  making  a  similar 
puncture  through  the  canine  fossa,  pushing  the  cannula  upwards 
at  an  angle  of  45  degrees. 

The  treatment,  when  the  condition  is  due  to  a  carious  tooth, 
usually  the  second  bicuspid  or  the  first  molar,  is  extraction  of  the 
tooth,  and  opening  upwards  through  the  socket  to  the  antrum  by 
directing  the  drill  or  gouge  towards  the  supraorbital  notch.  The 
cavity  is  irrigated,  and  permanent  drainage  secured  by  a  gold  or 
silver  tube,  which  may  be  closed  with  a  stopper  during  meals.  Irri- 
gation may  be  practised  likewise  through  the  natural  opening, 
or  through  an  opening  made  through  the  inferior  meatus  or  canine 
fossa.  Small  openings  of  this  character  are  exploratory  or  palUative 
and  are  not  suited  for  chronic  cases.  The  radical  operation  is  per- 
formed by  making  an  incision  at  the  junction  of  the  buccal  and 
alveolar  mucous  membranes,  and  opening  the  antrum  with  a  gouge 
through  the  canine  fossa,  about  one  inch  above  the  border  of  the 
gum,  on  a  level  with  the  second  bicuspid  tooth.  The  opening  may  be 
enlarged  sufficiently  to  explore  and  curette  the  antrum  thoroughly, 
and  a  counteropening  may  be  made  into  the  inferior  meatus  of 
the  nose.  A  tube  may  be  passed  through  both  of  these  openings 
and  the  cavity  irrigated  daily. 

Tumors  of  various  kinds  may  develop  in  the  antrum;  about  two- 
thirds  are  malignant.     The  so-called  hydrops,  or  dropsy  of  the  an- 


RESPIRATORY   SYSTEM  599 

tnnn,  is  practically  always  due  to  cystic  degeneration  of  tumors, 
or  to  cysts  connected  with  the  tooth  follicles,  although  a  true  dropsy 
from  closure  of  the  natural  opening  of  the  antrum  is  said  to  occur. 
Large  growths  cause  expansion  of  the  walls  of  the  antrum,  and  when 
malignant  soon  spread  to  adjacent  parts.  Transillumination  and 
percussion  will  give  the  same  results  as  in  empyema,  and  the  intro- 
duction of  a  small  cannula  will  determine  the  presence  or  absence  of 
fluid  and  the  density  of  the  growth.  In  doubtful  cases  the  cheek 
may  be  reflected  as  for  excision  of  the  jaw  and  the  anterior  wall  of  the 
antrum  removed.  Polyps,  cysts,  and  other  benign  tumors  may  be 
removed  through  this  opening;  if  malignant  disease  is  found,  the 
entire  upper  jaw  should  be  resected. 

LARYNX  AND  TRACHEA 

Congenital  fissures  and  fistulce,  laryngocele  and  tracheocele^  and 
wounds  of  the  air  passages,  have  been  referred  to  in  the  chapter  on 
surgery  of  the  neck. 

Foreign  bodies  in  the  air  passages  may  be  of  any  nature,  provid- 
ing they  are  small  enough  to  enter  the  larynx  or  trachea.  Those 
most  often  found  are,  in  the  order  of  their  frequency,  a  grain  of  corn, 
watermelon  seed,  bean,  and  grain  of  coffee.  Congenital  defects  or 
destruction  of  the  epiglottis  by  ulceration,  certain  diseases  like 
bulbar  paralysis,  and  unconsciousness  from  any  cause,  predispose  to 
this  accident.  Foreign  bodies  may  be  introduced  through  the 
glottis  or  through  an  artificial  opening  in  the  trachea,  and  they  may 
penetrate  from  without,  as  a  bullet,  needle,  or  other  sharp  body. 
They  may  ulcerate  into  the  respiratory  tree  from  the  esophagus, 
mediastinum,  or  one  of  the  subphrenic  organs,  stomach,  colon,  liver, 
or  spleen,  and  they,  may  be  formed  in  the  lung  itself  {lung  stones) . 

If  not  arrested  in  the  pharynx  or  larynx,  or  of  such  a  nature  as  to 
catch  in  the  wall  of  the  trachea,  the  foreign  body  usually  descends 
into  the  right  bronchus,  because  of  its  greater  diameter  and  because 
the  bronchial  septum  is  situated  to  the  left  of  the  median  line.  For- 
eign bodies  may  be  expelled  through  the  mouth  or  through  an  arti- 
ficial opening;  they  may  be  coughed  into  the  pharynx  and  swallowed; 
and  rarely  may  they  gain  exit  through  the  chest  wall  by  ulceration. 
Vegetable  substances  swell  and  sometimes  sprout.  Death  is  due  to 
asphyxia  from  complete  blocking  of  the  respiratory  channel  or 
from  edema  or  violent  spasm  of  the  glottis,  or  it  occurs  later  from 
septic  inflammation.  Rarely  hemorrhage  may  cause  a  fatal  issue, 
as  in  a  case  in  which  an  inhaled  dart  pierced  the  innominate  artery. 
If  the  foreign  body  is  not  large  enough  to  block  the  air  channel 


6oO  MANUAL    OF    SUEGERY 

completely,  there  are  great  dyspnea,  violent  cough,  lividity  of  the 
countenance,  writhing  of  the  patient,  and  partial  insensibihty, 
followed  by  expulsion  of  the  foreign  body  or  a  variable  lull  in  the 
symptoms,  then  by  recurrence  of  the  symptoms,  and  so  on  until 
spasm  or  edema  of  the  glottis  causes  asphyxia,  or  the  body  descends 
into  the  lung. 

The  diagnosis  is  usually  made  from  the  history,  but  if  the  patient 
be  unconscious  or  a  child  from  whom  no  history  can  be  obtained,  the 
symptoms  may  be  mistaken  for  asthma,  pertussis,  epilepsy,  apoplexy 
diphtheria,  cardiac  disease,  spasmodic  croup,  laryngismus  stridulus, 
edema  and  ulceration  of  the  larynx,  the  laryngeal  crisis  of  locomotor 
ataxia,  or  for  worms.  Even  after  expulsion  doubt  may  arise,  owing 
to  the  persistence  of  symptoms  due  to  irritation.  In  children  with 
sudden  respiratory  difficulty  one  should  think  always  of  a  foreign 
body.  The  breathing  is  slow  compared  with  that  of  disease,  inspira- 
tion prolonged  and  difficult  with  retraction  of  the  lower  ribs,  and  the 
respiratory  murmur  diminished  or  absent  on  the  corresponding  side 
if  there  be  impaction  in  the  bronchus,  the  pulmonary  resonance, 
however,  remaining  normal.  The  symptoms  are  intermittent  and  in 
the  beginning  there  is  no  fever.  Sometimes  the  foreign  body  may  be 
heard  rising  and  falling  in  the  trachea  with  each  respiration.  The 
pharynx  may  be  explored  with  the  finger,  the  larynx  and  upper  part 
of  the  trachea  with  the  laryngoscope,  the  bronchi  with  the  broncho- 
scope. It  should  be  recalled  that  blocking  of  the  esophagus  may 
cause  suffocative  symptoms.  When  the  infective  sequelae  from 
irritation  of  a  foreign  body  have  become  estabhshed,  the  diagnosis 
may  be  impossible  without  a  guiding  history.  These  cases  must  be 
differentiated  from  inflammatory  diseases  from  other  causes,  and 
from  chronic  largyneal,  tracheal,  or  bronchial  stenosis,  which  may 
be  extrinsic  or  intrinsic.  As  extrinsic  causes  may  be  mentioned  cica- 
tricial contractures;  localized  emphysema;  enlarged  thyroid,  thymus, 
or  lymphatic  glands;  extensive  pericardial  exudate;  dilatation  of  the 
left  auricle;  disease  or  injury  of  the  clavicle,  sternum,  or  vertebrae; 
and  cervical  or  mediastinal  cyst,  abscess,  neoplasm,  or  aneurysm. 
Among  the  intrinsic  causes  are  malformations;  neoplasms;  inflamma- 
tory thickening;  intussusception  of  the  trachea;  paralysis  of  the 
posterior  cricoarytenoids;  longitudinal  involution  of  the  trachea 
after  tracheotomy;  adhesions  of  the  epiglottis,  vocal  bands,  or 
arytenoids;  cicatrices,  syphihtic.  tuberculous,  or  traumatic;  and 
cicatrices  following  diseases  like  scarlatina,  diphtheria,  variola, 
rubeola,  an  enteric  fever.  The  characteristic  inspiratory  dyspnea 
is  sufficient  to  establish  the  diagnosis  of  stenosis.     If  the  voice  is 


RESPIRATORY    SYSTEM  6oi 

altered,  with  i)ain  and  rhoncus  in  a  larynx  whose  pitch  rises  and  falls 
with  each  respiration,  the  lesion  is  probably  in  the  larynx,  and  the 
diagnosis  may  be  confirmed  by  examination  with  reflected  light. 
Dysphagia  has  been  observed  in  some  cases,  and  the  head  is  apt  to  be 
held  backward  in  laryngeal  constriction,  and  slightly  depressed  with 
extended  neck  in  tracheal  stenosis.  The  respiratory  murmur  is 
diminished  over  both  lungs  in  any  constriction  above  the  tracheal 
bifurcation,  and  the  voice  may  be  weakened  owing  to  the  lessened 
column  of  air  impinging  on  the  vocal  bands.  Fixed  pain  and  rhon- 
cus, with  visual  examination  through  the  mouth,  would  locate  the 
stricture  in  the  trachea.  Narrowing  of  a  bronchus  may  be  recog- 
nized by  physical  examination  of  the  chest,  or  by  direct  inspection 
with  the  bronchoscope.  Diminished  respiratory  dilatation  of  one 
lung,  as  evinced  by  inspection,  palpation,  and  mensuration,  with 
diminished  vesicular  murmur  and  vocal  fremitus,  and  retention  of 
resonance,  can  be  caused  only  by  narrowing  of  the  bronchus  or 
pneumothorax.  A  whiring  rhoncus  occupying  the  same  place  and 
having  the  same  character  and  intensity  on  different  examinations, 
with  fixed  pain  and  thrill  over  the  spot  corresponding  to  a  bronchus, 
will  definitely  settle  the  point  of  constriction.  The  diagnosis  of  a 
foreign  body  would  be  made  by  excluding  the  other  causes  of  ob- 
struction.    An  X-ray  plate  might  facilitate  the  differentiation. 

The  treatment  in  a  great  emergency  is  to  thrust  a  knife  through 
the  cricothyroid  membrane;  if  there  be  less  urgency,  a  low  and 
rapid  tracheotomy  may  be  performed;  and  if  the  patient  is  seen 
during  a  quiescent  period,  a  careful  examination  should  be  made. 
When  above  the  vocal  bands  the  body  may  be  removed  wdth  the 
finger  or  forceps,  but  when  in  the  larynx  below  this  point  and  irregu- 
lar or  jagged,  permenant  injury  to  the  vocal  bands  may  follow 
forcible  extraction  from  above.  Foreign  bodies  in  the  trachea  or 
the  bronchi  should,  whenever  possible,  be  removed  through  a 
bronchoscope.  The  best  bronchoscope  is  probably  that  devised  by 
Jackson.  It  is  a  long,  sti'aight,  slender  speculum,  wath  an  electric 
lamp  at  the  distal  end.  Under  local  anesthesia  the  glottis  is  exposed 
with  Jackson's  direct  laryngoscope,  the  patient  being  in  the  dorsal 
position  with  the  head  fully  extended,  i.e.,  the  occiput  is  forced 
down  toward  the  shoulders,  thus  elevating  the  anterior  part  of  the 
neck.  The  bronchoscope  is  passed  through  the  laryngoscope  into  the 
larynx,  the  laryngoscope  is  withdrawn,  and  a  ''bite-block  inserted  to 
prevent  the  patient  biting  the  thin  walled  bronchoscope.  The 
bronchial  tree  is  exceedingly  elastic  and  flexible,  and  may  be  explored 
by  following  the  lumen  by  sight."     During  the  exploration  "the  head 


6o2  MANUAL    OF    SUEGERY 

and  neck  should  be  out  in  the  air  beyond  the  table  and  supported  by 
an  assistant,  so  that  the  head  may  be  freely  movable  as  needed.     For 
instance,  it  must  be  moved  to  the  right  for  the  bronchoscope  to 
enter  the  left  bronchus,  and  vice  versa  to  enter  the  right  bronchus; 
and  it  must  be  slightly  lowered  to  enter  the  middle  lobe  bronchus 
of  the  right  side,  raised  to  enter  the  posterior  branch  bronchi" 
(Jackson).     Secretions  are  removed  by  aspiration  or  by  sponging. 
Foreign  bodies  are  removed  with  suitable  forceps.     The  sooner  the 
bronchoscopic  examination  is  made  the  greater  the  chances  of  success, 
as  after  twelve  hours  the  foreign  body  may  be  concealed  by  swollen 
mucous  membranes.     Successful  removal  has  been  affected,  however, 
even  after  years.     If  impossible  or  injudicious  to  extract  the  body 
from  above,  the  patient  may  be  inverted  and  succussed  with  a  pillow, 
a  procedure  which  is  occasionally  successful,  especially  when  the 
alien  is   small,   round,   and   heavy.     Inversion,   however,   without 
adequate  means  for  immediately  opening  the  trachea,  is  dangerous, 
because  of  the  possibility  of  death  from  impaction  or  spasm  of  the 
glottis,  the  foreign  body  suddenly  striking  the  larynx  from  below. 
If   inversion   fail,   the   trachea   should  be  open  low  down  though 
the   symptoms   are   even  not  urgent,   because   of   the   danger   of 
death  from  impaction  or  convulsive  closure  of  the  glottis,  or  from 
subsequent  inflammation.    The  body  is  frequently  expelled  as  soon  as 
the  trachea  is  opened;  expulsion  may  be  facilitated  by  turning  the 
patient  face  downward,   or  by  inversion  and  succession.     These 
measures  f aihng,  a  careful  search  should  be  made,  and  removal  effected 
with  finger,  forceps,  scoop,  hook,  probe,  coin  catcher,  or  wire.     The 
bronchi  may  be  inspected  with  a  short  bronchoscope  introduced 
through  the  tracheotomy  wound.     A  powerful  magnet  may  attract 
bodies  Like  needles,  and  a  Bigelow  evacuator  may  be  used  to  aspirate 
small  foreign  bodies,  if  all  efforts  are  unavailing,  the  wound  should  be 
kept  open  by  sutures  or  hooks,  and  a  second  trial  made  the  next 
day.     A  tracheotomy  tube  would  hinder  expulsion  of  the  foreign 
body.    Laryngotomy,  because  of  the  danger  of  injuring  the  vocal 
bands,  should  be  performed  only  when  the  foreign  body  is  in  the 
larynx   and   cannot   be   removed   in   any   other   manner.     Several 
attempts  have  been  made  to  remove  foreign  bodies  in  the  bronchi 
which  could  not  be  dealt  with  through  a  low  tracheotomy  wound, 
by  splitting  the  sternum  or  by  opening  the  thorax  posteriorly,  with, 
we  believe,  but  a  single  success.     If  a  foreign  body  causes  pulmonary 
abcess  or  gangrene  which  can  be  localized,  these  should  be  opened 
and  drained,  when  the  irritating  body  may  be  detected,  or  perhaps 
discharged  later. 


RESPIRATORY    SYSTEM  603 

Edematous  laryngitis  (edema  of  the  glottis)  niu}-  be  caused  by 
other  forms  of  laryngitis,  by  injuries,  such  as  fractures  of  the  larynx, 
scalds,  and  foreign  bodies,  by  inflammatory  conditions  in  the  vicinity, 
such  as  cellulitis  of  the  neck,  and  by  Bright's  disease,  angioneurotic 
edema,  the  acute  infectious  fevers,  and  the  internal  administration 
of  potassium  iodid  for  other  forms  of  laryngeal  trouble.  The 
symptoms  are  interference  with  breathing,  particularly  inspiration, 
with  cyanosis,  etc.,  as  the  obstruction  becomes  more  complete. 
The  diagnosis  is  made  by  the  laryngoscope  and  by  feehng  the  swollen 
epiglottis  with  the  linger.  The  treatment  in  the  milder  cases  is 
multiple  punctures  or  scarification  of  the  swollen  tissues,  the  inhala- 
tion of  steam  laden  with  compound  tincture  of  benzoin,  and  ice  to  the 
neck.  In  more  severe  cases  high  tracheotomy  should. be  performed, 
not  waiting  until  the  patient  is  in  extremis.  Intubation  is  to  be 
preferred,  providing  the  swelling  is  not  too  great  to  prevent  the 
introduction  of  a  tube. 

Chrondritis  is  always  associated  with  perichondritis,  and  may  be 
due  to  trauma,  chronic  laryngitis,  syphilis,  tuberculosis,  epithehoma, 
typhoid  fever,  or  the  exanthemata.  The  cricoid  and  arytenoid 
cartilages  are  most  frequently  affected.  Necrosis  may  occur  and 
pus  may  form  {abscess  of  the  larynx),  which  may  discharge  internally 
or  externally;  subsequently  cicatricial  contraction  is  very  apt  to 
cause  stenosis.  The  symptoms  are  pain,  tenderness,  cough,  hoarse- 
ness, dysphagia,  and  dyspnea.  SwelHng  may  be  noticed  externally, 
or  perhaps  detected  only  with  the  laryngoscope.  The  treatment  is 
much  like  edema  of  the  glottis.  Abscesses  may  be  opened  within 
the  larynx  or  externally,  according  to  where  they  point.  In  the 
later  stages  removal  of  necrotic  cartilage  may  be  indicated. 

Syphilis  of  the  larynx  may  appear  in  the  secondary  stage  as 
mucous  patches  or  condylomata,  and  in  the  tertiary  stages  as  a 
gummatous  degeneration,  causing  extensive  destruction  of  tissue 
with  subsequent  cicatrization  and  stenosis.  A  subacute  or  chronic 
laryngitis  without  ulceration,  causing  Httle  or  no  trouble  beyond 
hoarseness,  also  occurs.  In  the  ulcerative  form  the  symptoms  are 
pain,  cough,  hoarseness,  dyspena,  and  dysphagia.  Syphilitic  lesions 
are  present  elsewhere  and  the  ulcers  revealed  by  the  laryngoscope 
are  usually  symmetrical;  in  the  tertiary  stage  the  epiglottis  is  par- 
ticularly apt  to  be  affected.  The  treatment  is  that  of  syphilis,  with 
the  insufflation  of  iodoform  into  the  larynx.  Potassium  iodid,  how- 
ever, must  be  used  with  caution,  lest  it  produce  edema  of  the  glottis. 
Tracheotomy  may  be  needed  for  edema,  convulsive  closure  of  the 
glottis,  or  later  for  cicatricial  stenosis. 


6o4  MANUAL    OF    SURGERY 

Tuberculosis  laryngitis  may  be  primary,  but  is  usually  secondary 
to  phthisis.  Tubercles  form,  break  down,  and  become  ulcers, 
which  coalesce  and  often  cause  great  destruction  of  tissue.  The 
most  common  situtaion  for  these  ulcers  is  about  the  arytenoid 
cartilages,  the  vocal  cords,  and  the  under  surface  of  the  epiglottis. 
Elevated  granulations  on  the  posterior  wall  of  the  larynx  are  strongly 
suggestive  of  tuberculosis.  The  subjective  symptoms  are  those  of 
syphilis  of  the  larynx.  Tubercle  bacilli  may  be  found  in  the  expecto- 
ration. The  treatment  is  that  of  tuberculosis  elsewhere,  with  applica- 
tions of  lactic  acid  and  insufflations  of  iodoform  or  thymol  iodid. 
Tracheotomy  may  be  needed  for  the  same  conditions  as  in  syphilis  of 
the  larynx. 

Tumors  of  the  larynx  may  be  benign  or  malignant.  The  papill- 
omata  are  the  most  common;  they  are  most  frequent  on  the  vocal 
cords  and  sometimes  undergo  an  epitheliomatous  change.  The 
symptoms  are  hoarseness  or  aphonia,  cough,  dyspnea,  and  sometimes 
pain  and  dysphagia.  In  adults  the  growth  may  be  seen  with  the 
laryngoscope;  the  warty-like  appearance  of  the  papilloma  is  dis- 
tinctive. The  treatment  is  intralaryngeal  removal  by  special  forceps 
or  snare,  or  by  cauterization.  Cysts  may  be  incised.  In  children 
and  in  extensive  subglottic  growths  it  will  usually  be  necessary  to 
split  the  thyroid  cartilage  in  the  middle  line  (thyrotomy)  and  deal 
directly  with  the  growth. 

Malignant  tumors  may  be  sarcomata,  but  are  usually  epitheliomta 
which  frequently  result  from  previously  benign  tumors  and  grow 
slowly.  The  symptoms  are  those  of  benign  tumors,  but  pain  shooting 
towards  the  ears  and  hemoptysis  are  more  frequent,  and  there  is  likely 
to  be  emaciation  and  lymphatic  involvement.  The  diagnosis  in  the 
early  stages  is  often  difficult;  in  doubtful  cases  a  piece  of  the  grow^th 
should,  if  possible,  be  secured  for  microscopic  examination.  The 
treatment  is  removal  of  the  growth  by  thyrotomy,  or  by  partial  or 
complete  laryngectomy,  according  to  its  extent.  A  preliminary 
tracheotomy  is  usually  required.  Cure  has  been  obtained  in  26.6 
per  cent,  of  the  cases  (Kocher).  Endolaryngeal  operations  are 
not  competent  to  deal  with  malignant  disease.  In  the  later  stages 
tracheotomy  may  be  performed  to  relieve  dypsnea. 

Tiuncrs  of  the  trachea  have  in  a  general  way  the  same  features  as 
those  of  the  larynx,  except  that  respiration  is  more  apt,  to  be  affected 
than  phonation.  The  tumor  may  be  of  any  variety,  is  often  recog- 
nized by  the  laryngoscope,  and  may  in  suitable  cases  be  excised 
through  a  tracheotomy  wound. 


RESPIRATORY    SYSTEM  605 

OPERATIONS  UPON  THE  AIR  PASSAGES 

Subhyoid  pharyngotomy  may  be  performed  to  gain  access  to  the 
pharynx  or  upjxT  ])art  of  the  larynx,  but  the  operation  is  rarely  used 
A  transverse  incision  is  made  between  the  hNoid  bone  and  the  thy- 
roid cartilage  and  the  ])harynx  opened,  the  epiglottis  being  detached 
from  the  tongue.  Intratracheal  insufllation  anesthesia,  or  a  pre- 
liminary tracheotomy  will  be  necessary  in  removing  growths,  etc., 
which  cause  much  hemorrhage.  The  structures  are  sutured  at  the 
completion  of  the  operation. 

Transhyoid  pharyngotomy  maybe  used  for  the  same  purposes  as 
the  above.  An  incision  is  made  in  the  median  line  from  the  chin  to 
the  thyroid  notch,  the  hyoid  bone  divided,  and  the  pharynx  opened. 
Etherization  by  intratracheal  insufflation  obviates  the  necessity  for 
a  preliminary  tracheotomy. 

Thyrotomy  exposes  the  interior  of  the  larynx  by  splitting  the 
thyroid  cartilage  in  the  median  line,  after  performing  tracheotomy 
and  inserting  a  tampon  cannula  into  the  windpipe,  or  continuing  the 
anesthesia  by  intratracheal  insufflation.  The  wound  in  the  thyroid 
cartilage  is  widely  separated  and  the  interior  of  the  larynx  exposed  to 
view.     The  wound  may  subsequently  be  closed  by  sutures. 

Laryngectomy  is  performed  for  malignant  disease  and  occasion- 
ally for  other  conditions,  such  as  extensive  stenosis  or  ulceration.  It 
may  be  complete  or  partial  according  to  the  extent  of  disease,  and  in 
a  few  cases  adjacent  portions  of  the  tongue,  pharynx,  and  esophagus 
have  been  excised.  After  unilateral  laryngectomy  the  patient  is 
able  to  speak,  after  total  laryngectomy  he  is  able  to  whisper.  A  low 
tracheotomy  should  be  performed  a  week  or  more  before  the  excision 
of  the  larynx,  especially  if  there  is  much  dyspnea,  in  order  to  accus- 
tom the  patient  to  breathe  through  the  tube,  to  faciUtate  anesthesia, 
and  to  lessen  the  time  of  the  larger  operation.  The  patient  is  ether- 
ized through  the  tracheotomy  wound  by  means  of  intratracheal  in- 
sufflation, or  chloroformed  after  the  insertion  of  a  tampon  cannula. 
A  median  incision  is  made  from  the  hyoid  bone  to  below  the  cricoid 
cartilage,  a  transverse  cut  made  at  either  end  of  this  incision,  the 
flaps  reflected,  the  larynx  isolated  by  blunt  dissection,  and  removed 
by  cutting  through  the  thyrohyoid  space  above  and  the  trachea  be- 
low. The  upper  end  of  the  trachea  is  sutured  to  the  skin  and  the 
wound  packed  with  gauze  and  partly  sutured,  the  patient  being  fed 
by  means  of  a  tub(^  introduced  into  the  esophagus  through  the  nose 
or  the  mouth.  The  cervical  lymphatic  glands  are  of  course  removed 
before  completing  the   operation.     When    healing  is  complete  the 


6o6  MANUAL    OF    SURGERY 

patient  may  wear  an  artificial  larynx.  Some  surgeons  prefer  perform- 
ing the  tracheotomy  immediately  before  the  laryngectomy,  others 
discard  the  preHminary  tracheotomy  altogether,  and  after  isolating  the 
larynx  sever  the  trachea,  suture  it  to  the  skin,  and  close  the  opening 
in  the  pharynx;  this  of  course  prevents  the  use  of  an  artificial  larynx. 

Larjmgotomy  is  an  emergency  operation  in  cases  of  laryngeal 
obstruction  from  any  cause.  A  vertical  incision  is  made  over  the 
cricothyroid  membrane,  the  cricothyroid  membrane  divided  trans- 
versely close  to  the  cricoid  cartilage,  and  a  tube  introduced.  The 
cricothyroid  artery  may  be  injured  and  require  a  ligature.  In  a 
great  emergency  the  whole  operation  may  be  completed  by  a  single 
transverse  incision  made  with  a  penknife,  and  the  patency  of  the 
opening  maintained  with  the  handle  of  the  knife.  The  operation  is 
not  applicable  to  children,  owing  to  the  small  size  of  the  cricothyroid 
space;  if  ever  performed  before  puberty,  it  should  be  combined  with 
division  of  the  cricoid  and  possibly  the  first  ring  of  the  trachea 
(laryngotracheotomy) . 

Tracheotomy  is  performed  for  serious  obstruction  to  respiration, 
for  the  removal  of  foreign  bodies,  and  as  a  preliminary  to  operations 
on  the  mouth,  pharynx,  or  larynx.  The  high  operation,  i.e.,  above 
the  isthmus  of  the  thyroid  gland,  is  always  selected  when  possible, 
because  in  this  situation  the  trachea  is  superficial  and  the  operation 
much  more  simple.  When  the  obstruction  is  low  down,  however, 
or  when  one  desires  to  search  for  a  foreign  body  in  the  trachea  or 
bronchi,  the  low  operation  is  indicated. 

High  tracheotomy  may  be  performed  under  a  general  or  a  local 
anesthetic,  or  indeed  in  urgent  cases  without  any  anesthetic.  A 
pillow  is  placed  under  the  shoulders  so  as  to  extend  the  head,  and  an 
incision,  exactly  in  the  median  line,  is  made  from  the  cricoid  down- 
wards for  one  and  one-half  inches,  dividing  the  skin  and  superficial 
and  deep  fascse.  The  trachea  is  now  exposed  by  separating,  if 
necessary,  the  sternohyoid  muscles.  The  isthmus  of  the  thyroid 
gland  normally  lies  over  the  third  and  fourth  tracheal  rings.  If  it  be 
in  the  way,  it  may  be  depressed  after  dividing  the  deep  fascia  trans- 
versely, or  it  may  be  incised  in  the  median  line,  without  ordinarily 
giving  rise  to  much  hemorrhage.  A  tenaculum  is  inserted 
below  the  cricoid  to  steady  the  trachea,  which  is  opened  from  below 
upwards,  being  careful  to  guard  the  knife  with  the  index  finger  so  as 
not  to  injure  the  posterior  wall.  Ordinarily  two  or  three  rings  are 
divided,  the  cut  being  exactly  in  the  middle  line.  A  pair  of  hemostats 
should  be  introduced  into  the  trachea  before  the  knife  is  withdrawn 
and  a  tracheotomy  tube  inserted  as  the  blades  of  the  forceps  are  sep- 


RESPIRATORY    SYSTEM  607 

arated.  The  tenaculum  should  not  be  removed  until  the  tube  is  in 
place.  The  tube  is  held  in  position  by  tapes  tied  around  the  neck. 
In  the  absence  of  a  tube  one  may  suture  the  edges  of  the  tracheal 
wound  to  the  skin.  Bleeding  from  the  small  veins  which  have  been 
divided  usually  ceases  promptly  when  the  trachea  is  opened.  The 
wound  is  sutured,  leaving  sufficient  opening  for  the  tube,  a  couple  of 
layers  of  gauze  are  placed  beneath  the  flange  of  the  tube,  and  one  or 
two  layers  moistened  with  boric  acid  solution  over  the  orifice  of  the 
tube. 

In  low  tracheotomy  the  skin  incision  may  reach  the  sternum,  but 
the  lower  part  of  the  wound  should  be  deepened  very  cautiously 
because  of  the  danger  of  wounding  the  innominate  vein  or  the  thyro- 
idea  ima.  Often  the  inferior  thyroid  veins  are  large  and  numerous 
and  lie  directly  over  the  trachea;  they  should  be  ligated  or  pushed 
aside.  If  need  be,  the  isthmus  of  the  thyroid  gland  may  be  pushed 
upwards.  The  rest  of  the  operation  is  pre- 
cisely the  same  as  the  high  operation.  In 
children  the  low  operation  is  extremely 
difficult  because  of  the  depth  and  small  size 
of  the  trachea,  the  shortness  of  the  neck, 
and  the  large  size  of  the  thymus  gland.  If 
the  obstruction  is  still  below  the  tracheo- 
tomv  opening  a  long  tube  or  catheter  mav 

possibly  be  passed  beyond  it.  '     ^^°-  3 07. -Tracheotomy  tube. 

Tracheotomy  tubes  are  made  of  hard  rubber,  silver,  or  aluminum. 
They  are  always  double,  the  outer  tube  having  a  flange  with  slots, 
through  which  tape  may  be  passed,  and  the  inner  tube  being  fastened 
to  the  outer  by  a  little  catch  on  the  side  so  that  it  may  be  re- 
moved and  cleansed  as  often  as  necessary  (Fig.  307). 
Some  of  these  tubes  are  provided  with  a  long  handle  or 
introducer  and  a  special  speculum-like  apparatus  or  dilator  to  facili- 
tate introduction,  but  such  are  usually  unnecessary.  When  a 
tracheotomy  is  performed  preliminary  to  operations  on  the  mouth, 
larynx,  etc.,  a  tampon  cannula,  i.e.,  one  encased  in  a  rubber  sac, 
which  may  be  inflated  in  order  to  fill  the  space  betw^een  the  tube  and 
the  tracheal  wall,  or  covered  with  a  compressed  sponge  which  swells 
when  moistened,  is  sometimes  employed  to  prevent  the  entrance  of 
the  blood  into  the  lungs,  although  with  intratracheal  insufflation 
anesthesia  such  appliances  are  not  needed. 

After  Treatment. — The  room  should  be  kept  at  a  uniform  tem- 
perature of  75°F.,  the  air  moistened  by  steam,  and  the  gauze  over  the 
tube  changed  as  often  as  the  patient  coughs,  so  that  the  mucus,  etc. 


6o8  MANUAL    OF    SURGERY 

will  not  fall  back  into  the  tube.  The  inner  tube  should  be  removed 
every  two  or  three  hours  by  the  nurse  and  cleansed,  the  outer  tube 
may  be  removed  once  a  day  by  the  physician  for  the  same  purpose. 
Mucus  in  the  trachea  may  be  extracted  by  a  sterile  feather  moistened 
with  bicarbonate  of  soda  solution,  20  grains  to  the  ounce.  If  there 
is  much  difficulty  in  breathing,  oxygen  may  be  given  by  intratracheal 
insufflation.  The  tube  should  be  removed  permanently  as  early  as 
possible,  but  the  time  that  it  should  remain  in  place  will  vary  greatly 
with  the  condition;  thus  after  the  removal  of  a  foreign  body  it  may 
be  only  twenty-four  hours,  in  some  cases  of  stenosis  it  may  be  for 
the  rest  of  the  patient's  life.  Tubes  are  constructed  with  an  opening 
in  the  convex  portion,  so  that  part  of  the  air  will  pass  through  the 
larynx;  if  breathing  is  free  when  the  outer  opening  is  plugged,  the 
tube  may  be  removed  with  safety.  Among  the  complications  of 
tracheotomy  may  be  mentioned  ulceration  of  the  trachea  from  a 
poorly  fitting  tube,  cellulitis,  secondary  hemorrhage,  mediastinal 
emphysema,  bronchitis,  pneumonia,  and  stenosis  of  the  larynx,  or 
trachea.  Stenosis  of  the  larynx  may  be  treated  by  gradual  dilatation 
with  O'Dwyer's  tubes,  or  in  some  cases  by  removing  the  cicatricial 
tissue  and  skin  grafting  the  interior  of  the  larynx. 

Intubation  of  the  larynx  may  be  used  for  many  forms  of  stenosis 
of  the  larynx,  but  is  chiefly  employed  in  that  form  due  to  diphtheria. 
It  is  rapidly  performed  with  much  less  risk  than  tracheotomy,  but 
requires  special  instruments,  and  the  presence  of  the  surgeon  if  the 
tube  should  be  coughed  up.  The  instruments  are  shown  in  Fig. 
308.  The  child  is  wrapped  in  a  blanket  to  control  the  arms  and 
legs,  and  is  held  upright  by  a  nurse  seated  in  a  chair,  while  an  assist- 
ant holds  the  head  upon  the  nurse's  left  shoulder  and  prevents  the 
mouth  gag  from  slipping.  A  long  piece  of  silk  is  passed  through  the 
small  opening  in  the  upper  part  of  the  tube,  the  tube  fastened  to 
the  introducer,  and  the  silk  looped  around  the  little  linger.  The  left 
index  finger  is  passed  into  the  throat,  and  draws  the  epiglottis  and 
base  of  the  tongue  forward,  while  the  tube  is  passed  along  it  into  the 
glottis.  The  left  index  finger  is  then  made  to  press  upon  the  head 
of  the  tube,  which  is  released  by  pulling  the  trigger  on  the  introducer, 
which  is  then  withdrawn.  When  one  is  assured  that  the  tube  is  in 
the  right  place  and  that  the  symptoms  are  relieved,  the  silk  loop 
may  be  cut  and  withdrawn  while  the  finger  is  again  made  to  press 
down  on  the  tube.  If  the  tube  is  coughed  up,  it  is  too  small  and 
the  next  larger  size  should  be  introduced.  In  cases  of  diphtheria 
the  membrane  may  be  pushed  before  the  tube  and  cause  asphyxia, 
which,  if  not  immediately  relieved  by  expulsion  of  the  membrane 


RESPIRATORY   SYSTEM 


609 


after  the  tube  has  been  pulled  out  by  the  string,  will  demand  tracheo- 
tomy, hence  instruments  for  this  operation  should  always  be  at  hand. 
The  ])atient  speaks  in  a  whisper,  and  is  apt  to  inhale  food  during 
deglutition,  hence  feeding  should  be  per  rectum  or  by  nasal  tube, 
although  some  advise  feeding  with  the  head  lower  than  the  body,  or 
the  giving  of  semi-solids,  which  will  more  easily  pass  over  the  glottis. 
The  tube  remains  in  place  several  days,  and  is  then  removed  with 


Fig.  308. — To  the  left  is  the  mouth  gag,  and  the  scale  for  determining  the  proper 
sized  tube  according  to  the  age  of  the  patient.  Next  is  the  introducer,  next  the 
extractor.  On  the  right  are  the  tubes,  which  are  expanded  above  the  rest  on  the  ven- 
tricular bands,  with  a  prominence  posteriorly  which  rests  between  the  arytenoid 
cartilages.  The  middle  of  the  tube  is  enlarged,  the  enlargement  resting  just  below  the 
vocal  cords,  to  prevent  displacement  of  the  tube  upwards  when  it  is  in  position.  Be- 
tween the  tubes  on  the  right  is  the  obturator,  which  fits  into  the  tube  and  is  screwed 
into  the  holder,  and  which  is  hinged  in  the  middle  so  that  it  may  be  withdrawn  after 
the  tube  is  in  position.  The  scale  indicates  the  length  of  tube  to  be  used,  measuring 
from  bolow  upward  the  figures  represent  the  age  of  the  child. 

the  child  in  the  same  position  as  for  introduction,  by  passing  the  left 
index  finger  down  to  the  tube  and  slipping  the  point  of  the  extractor 
into  its  opening,  the  tube  being  engaged  by  pressing  the  spring  on 
the  shank  of  the  extractor. 


SURGERY  OF  THE  CHEST 

Contusion  of  the  chest  may  cause  superficial  bruising  of  the  skin, 

laceration  of  the  muscles,  fracture  of  any  portion  of  the  wall  of  the 

thorax,   or  more  or  less  extensive  injury  to  the  contained  viscera. 

Occasionally  a  severe  blow  on  the  chest  or  epigastrium  (so-called 

39 


6lO  MANUAL    OF    SURGERY 

solar  plexus  blow)  will  be  followed  by  severe  shock  or  even  death, 
without  causing  any  gross  anatomical  change;  this  condition  has  been 
termed  concussion  of  the  chest  and  is  probably  due  to  direct  concussion 
of  the  heart  muscle  or  its  nerve  mechanism.  Owing  to  the  lack  of 
functionating  valves  in  the  jugular  and  facial  veins,  forcible  compres- 
sion of  the  chest  of  some  minutes'  duration,  such  as  may  occur  in  a 
struggling  mob,  may  cause  a  bluish  or  black  discoloration  of  the  face 
and  neck,  subconjunctival  ecchymosis,  and  hemorrhages  into  the 
retina  and  brain  (traumatic  asphyxia).  Rupture  of  the  lung  is  recog- 
nized by  cough,  dyspnea,  hemoptysis,  subcutaneous  emphysema, 
and  hemo-pneumothorax.  Ruptures  of  the  large  vessels,  trachea, 
or  esophagus  are  associated  with  such  widespread  injury  that  death 
quickly  follows.  For  injuries  of  the  heart  see  chap,  xv,  and  for 
rupture  of  the  diaphragm,  chap,  xxvii.  The  treatment  of  con- 
tusion of  the  chest  is  reaction  from  shock,  and  immobilization  of  the 
thorax  as  in  fracture  of  the  ribs.  In  the  presence  of  marked  evidences 
of  internal  hemorrhage,  thoracotomy  and  efforts  to  check  the  bleeding 
are  indicated.  The  treatment  of  pneumothorax  is  given  on  a  later 
page. 

Wounds  of  the  chest  may  be  penetrating  or  non-penetrating; 
the  latter  are  treated  as  wounds  elsewhere.  Penetrating  wounds  are 
usually  caused  by  stabs  or  bullets.  The  diagnosis  may  be  made  by 
signs  of  injury  to  the  viscera,  or  by  exploration  of  the  disinfected 
wound  with  a  sterile  finger;  the  latter  is  always  advisable,  particu- 
larly in  wounds  in  the  neighborhood  of  the  heart,  or  below  the  sixth 
rib,  as  in  this  situation  penetration  of  the  diaphragm  and  injury 
to  the  abdominal  viscera  may  easily  occur.  Wounds  of  the  heart 
have  already  been  discussed  and  injuries  of  the  abdominal  viscera 
will  be  considered  in  a  subsequent  chapter.  The  possible  symptoms 
of  a  penetrating  wound  of  the  lung  are  those  of  rupture  of  the  lung 
with  a  bleeding  and  a  sucking  external  wound. 

The  treatment  in  the  absence  of  serious  hemorrhage  or  the  lodge- 
ment of  a  foreign  body  is  debridement,  suture  of  the  external 
wound  and  immobilization  of  the  affected  side  of  the  chest.  Hemor- 
rhage from  the  internal  mammary  or  intercostal  artery  may  be  con- 
trolled by  ligation,  or  by  pushing  a  gauze  sac  between  the  ribs  and 
filling  the  inner  end  of  the  sac  with  gauze  so  that  when  drawn  upon 
it  will  make  pressure  from  within  outwards.  Excepting  extensive 
wounds,  bleeding  from  the  lung  is  rarely  fatal,  as  the  bleeding  is 
checked  by  collapse  of  the  lung.  In  the  absence  of  external  hemor- 
rhage, serious  loss  of  blood  is  diagnosticated  by  the  constitutional 
signs   of   acute   anemia    and    a   rapidly   accumulating  hemothorax. 


RESPIRATORY    SYSTEM  6ll 

Bastinelli  sug<j;(.'sts  the  aspiration  of  the  blood  and  partial  replacement 
with  air.  If  the  bleeding  continues  the  thoracic  cavity  should  be 
opened  through  a  large  intercostal  incision,  the  hemorrhage  con- 
trolled by  catgut  sutures  the  pleural  cavity  washed  free  of  blood  and 
the  intercostal  wound  closed,  but  in  the  presence  of  serious  symptoms 
one  or  more  ribs  should  be  resected,  and  the  wounded  lung  dealt 
with  directly  by  sutures  or  gauze  packing.  Hemothorax  of  lesser 
degree,  or  that  form  due  to  hemorrhagic  pleurisy  or  tumors  of  the 
lung  or  pleura,  does  not  require  special  surgical  treatment  unless  it 
causes  pressure  symptoms  or  becomes  infected;  in  the  former  case 
aspiration,  and  in  the  latter  resection  of  a  rib  and  drainage  would 
be  indicated.  Foreign  bodies  should  be  removed  if  easily  accessible, 
and  the  same  rules  as  to  the  examination  of  the  vulnerating  instru- 
ment, the  clothing,  etc.,  apply  here  as  elsewhere.  If  the  foreign  body 
is  not  easily  found,  it  should  be  allowed  to  remain,  unless  it  gives 
rise  to  subsequent  trouble,  when  it  may  be  definitely  localized  by  the 
X-ray  and  its  removal  effected,  if  such  be  deemed  advisable.  Petit 
de  la  Villeon  has  developed  a  method  of  removing  foreign  bodies 
from  the  lungs  by  moving  the  patient  before  a  fluroscope  and 
thus  guiding  the  approach  to  the  foreign  body  of  metal  forceps 
introduced  through  a  puncture  wound  of  the  intercostal  tissues. 
With  the  exception  of  pneumocele,  the  complications  of  injuries  to 
the  chest  are  inflammatory  in  nature,  viz.,  cellulitis,  pleurisy, 
empyema,  pneumonia,  abscess  or  gangrene  of  the  lung,  mediastinal 
abscess,  and  peri-,  myo-  or  endocarditis. 

Hernia  of  the  lung  (pneumocele)  is  rare;  it  is  the  result  of  laceration 
of  the  intercostal  structures  w-ithout  involvement  of  the  skin,  or 
follows  a  wound  owing  to  stretching  of  the  cicatrix.  It  has  an  im- 
pulse on  coughing,  crepitates  beneath  the  fingers,  and  a  vesicular 
murmur  can  be  heard  on  auscultation.  It  is  treated  by  a  pad  or 
truss.  In  contradistinction  to  a  hernia,  a  prolapse  of  the  lung  is  a 
protrusion  of  the  lung  into  an  open  wound.  It  should  be  reduced 
and  the  opening  closed,  or  if  badly  infected  and  gangrenous,  or 
densely  adherent,  it  may  be  amputated. 

Emphysema  of  the  subcutaneous  tissues,  the  result  of  inju'y  to 
the  lung,  rarely  requires  any  treatment  and  gradually  disappears. 
If  excessive  and  interfering  with  respiration,  multiple  punctures  may 
be  made. 

P*neumothorax  (air  in  the  pleural  cavity)  is  almost  always  asso- 
ciated with  the  presence  of  pus,  blood,  or  serum.  Ninety  per  cent 
of  all  cases  are  due  to  phthisis.  Pneumothorax  may  occur  in  children 
from  a  ruptured  lung  without  a  fracture  of  the  ribs,  owing  to  the 


6l2  MANUAL    OF    SUEGERY 

elasticity  of  the  ribs.  Air  may  enter  the  pleural  sac  through  a  wound 
in  the  chest  wall  or  lung,  it  may  come  from  the  colon,  stomach,  or 
esophagus  as  the  result  of  suppurative  or  malignant  disease,  and  it 
may  be  produced  by  aerogenic  microbes.  The  symptoms,  when  a 
large  amount  of  air  is  suddenly  introduced,  are  pain,  dyspnea 
cyanosis,  and  rapid  weak  pulse.  These  symptoms  are  seldom  seen 
during  operations  involving  the  pleural  cavity,  because  of  the  fre- 
quency of  pleural  adhesions  and  the  strong  coherence  which  normally 
exists  between  the  pleural  laminae.  The  signs  of  pneumothorax  are 
bulging  and  immobihty  of  the  affected  side,  displacement  of  the 
heart,  lessening  or  absence  of  vocal  fremitus  and  breath  sounds, 
tympany  on  percussion  (rarely  dulness),  metallic  tinkling,  and  a 
metalhc  quality  in  the  voice,  in  the  rales,  and  in  the  sound  heard 
when  percussing  the  chest  by  using  a  coin  as  a  plexor  and  one  as  a 
pleximeter  (coin  test).  There  may  be  signs  of  fluid  in  the  cavity, 
and  a  splashing  sound  obtained  by  shaking  the  patient.  The  X-ray 
will  give  an  intense  clearness  over  the  air  sac.  Treatment  is  not 
required  as  long  as  respiration  is  not  impeded,  indeed  a  little  pneumo- 
thorax may  be  beneficial  in  giving  rest  to  an  affected  lung,  but  if  the 
breathing  be  difficult  and  the  heart  displaced,  the  air  may  be  re- 
moved by  aspiration,  or  if  associated  with  pus,  by  wide  intercostal 
incision  or  resection  of  a  rib  and  drainage.  In  cases  resulting  from 
an  external  wound  the  pleural  opening  may  be  sutured  or  plugged, 
or  the  lung  or  diaphragm  may  be  stitched  to  the  chest  wall.  The 
Fell-0'Dwyer  apparatus  (chap,  ii)  has  been  suggested  to  anticipate 
and  combat  acute  operative  pneumothorax;  for  the  same  purpose 
Sauerbruch  operates  inside  a  cabinet  in  which  the  air  pressure  is 
negative,  the  patient's  head  extending  beyond  the  cabinet,  an  air 
tight  collar  being  fitted  to  his  neck.  Brauer  uses  positive  pressure, 
i.e.,  an  air  tight  mask  is  fitted  to  the  patient's  head  and  the  anesthetic 
at  a  pressure  above  that  of  the  atmosphere,  given  by  a  special  ap- 
paratus. Although  more  convenient  than  the  Sauerbruch  method, 
difficulty  is  encountered  in  adjusting  the  mask  if  the  patient  vomits, 
a  disadvantage  which  has  been  met  by  administering  the  anesthetic 
through  a  tracheotomy  wound.  Intratracheal  anesthesia  (chap,  ii) 
seems,  at  the  present  time,  the  best  method  for  preventing  pneumo- 
thorax during  intrathoracic  operations.  Some  surgeons,  the  day 
before  operations  on  the  lung,  suture  both  layers  of  the  pleura 
together,  or  slowly  induce  a  pneumothorax.  The  safety  with  which 
surgeons  have  operated  upon  chest  wounds  during  the  war  using 
simple  inhalation  anesthesia  makes  it  questionable  whether  these 
measures  are  necessary.     Elsberg  states  that  when  the  patient  is 


KESPIRATORV    SYSTEM  613 

in  the  dorsal  position  the  heart  falls  backwards  and  pulls  with 
it  the  visceral  pleura  of  the  anterior  mediastinum,  thus  predisposing 
to  pneumothorax;  consequently  he  advises  opening  the  pleural 
cavity  with  the  patient  in  the  ventral  position. 

Serous  pleural  effusion  is  usually  the  result  of  pleurisy,  which  may 
be  primary,  or  secondary  to  trauma  or  disease  of  the  lung;  it  may 
be  caused  also  by  tumors  of  the  lung,  or  disease  of  the  heart,  liver, 
or  kidney.  Symptoms  may  be  absent,  or  there  may  be  pain,  cough, 
dyspnea,  and  in  inflammatory  cases  fever  and  leukocytosis.  The 
signs  of  fluid  in  the  chest  are  immobility  and  enlargement  of  the 
affected  side,  widening  with  perhaps  bulging  of  the  intercostal  spaces, 
displacement  of  the  heart,  diminished  or  absent  vocal  fremitus, 
dulness  or  flatness  on  percussion  which  may  change  with  alteration 
in  the  position  of  the  patient,  tympany  above  the  fluidj^  feeble  or 
absent  breath  sounds  and  vocal  resonance,  and  opacity  as  revealed 
by  the  X-ray.  In  some  cases  there  is  bronchial  breathing  and  ego- 
phony.  The  treatment  of  serous  effusions  when  large  in  amount  or 
producing  pressure  symptoms,  or  in  any  case  not  quickly  relieved 
by  medical  treatment,  is  aspiration. 

Pyothorax,  or  empyema  fpus  in  the  pleural  cavity),  may  be  due 
to  infection  of  the  pleural  cavity  by  a  wound,  or  to  extension  of  a 
suppurative  process  of  the  lung,  neck,  or  abdomen,  but  is  commonly 
secondary  to  infection  of  a  serous  pleural  effusion.  Moschcowitz 
holds  that  all  originate  in  one  or  more  subpleural  alveolar  abscessses 
which  rupture  into  the  pleural  cavity.  The  organism  present  will 
vary  with  the  cause;  it  may  be  the  staphylococcus,  streptococcus, 
pneumococcus.  colon  bacillus,  tubercle  bacillus,  t>'phoid  bacillus, 
etc.  The  symptoms  and  signs  are  those  of  serous  effusion,  with,  in  a 
typical  case,  irregular  fever,  possibly  chills  and  sw^eats.  leukocytosis, 
edema  of  the  chest  wall,  and  absence  of  the  whispered  pectoriloquy 
which  may  be  heard  in  serous  effusions  (BaccelWs  sign).  The 
diagnosis  is  contirmed  by  exploratory  puncture.  In  some  cases  the 
pulsations  of  the  heart  are  transmitted  through  the  eff'usion  {pulsating 
empyema).  The  pus  may  be  localized  by  adhesions  {encapsulated 
empyema),  or  fill  the  whole  pleural  cavity  {total  empyema).  Spon- 
taneous recovery  is  possible  but  very  rare.  An  empyema  may  per- 
forate the  chest  wall  {empyema  necessHatus),  or  it  may  break  into 
the  lung,  esophagus,  stomach,  pericardium,  or  peritoneum.  Rarely 
it  may  form  a  lumbar  or  psoas  abscess.  In  acute  cases  the  pleura  is 
but  httle  altered,  and  although  the  lung  is  compressed,  it  readily 
expands  when  drainage  is  established.  In  chronic  cases,  however 
reexpansion  is  prevented  by  sclerotic  changes  in  the  lung  and  by  the 


6l4  MANUAL    OF    SURGERY 

dense  and  thickened  pleura.  In  these  cases  nature  tries  to  obliterate 
the  cavity  by  causing  a  hypertrophy  of  the  opposite  lung,  an  ascent 
of  the  abdominal  viscera  on  the  affected  side,  a  sinking  in  of  the 
chest,  a  lateral  curvature  of  the  spine,  and  an  abundant  growth  of 
granulations  from  the  pleura.  If  the  cavity  is  large,  healing  can  take 
place  only  with  the  aid  of  surgery.  The  prognosis  is  considerably 
modified  by  the  character  of  the  infection  thus  a  pneumococcal 
empyema  in  the  early  stages  may  often  be  cured  by  aspiration  alone, 
as  the  organisms  quickly  perish,  while  the  presence  of  other  pyogenic 
bacteria  will  always  indicate  free  drainage,  and  even  then  extensive 
subsequent  operations  may  be  demanded.  A  tuberculous  empyema 
will  of  course  present  a  grave  prognosis.  Cultures  in  these  cases, 
as  well  as  in  a  late  pneumococcal  empyema,  may  be  sterile.  The 
earlier  drainage  is  instituted,  the  greater  the  chance  of  reexpansion  of 
the  lung. 

The  treatment  of  acute  cases  is  aspiration,  intercostal  incision, 
or  rib  resection,  depending  upon  the  character  of  the  exudate,  chronic 
cases  may  demand  the  Estlander,  Schede,  or  Fowler  operation.  The 
principle  in  acute  cases  is  to  remove  the  fluid  with  out  the  collapse  of 
the  lungs,  in  chronic  cases  to  obhterate  the  cavity  by  causing  the 
chest  wall  to  collapse  or  the  lung  to  expand,  by  removing  adhesions 
or  the  thickened  pleura.  Dunham  and  Moschowvitz  advise  the 
repeated  aspiration  of  the  plural  effusions  until  they  become  macro- 
scopically  purulent.  Before  this  stage  pleural  adhesions  are  not 
formed  and  if  a  pneumothorax  is  produced  not  only  collapse  of  the 
involved  lungs  occurs  but  also  of  the  opposite  lung.  According  to 
Graham  and  Bell  the  normal  mediastinal  tissues  are  so  mobile  the 
thorax  must  be  considered  as  one  cavity  in  relation  to  pressure  changes. 

Paracentesis  thoracis  (tapping)  may  be  performed  with  an 
ordinary  trocar  and  cannula,  but  as  this  permits  the  introduction  of 
air,  aspiration  should  be  employed  whenever  possible.  A  hypodermic 
or  an  antitoxin  syringe,  with  a  long  and  strong  needle  of  large  calibre, 
may  be  used  for  diagnostic  purposes.  Fig.  309  shows  an  aspirator. 
The  stopper  is  inserted  into  a  large  glass  bottle,  the  stop-cock  A 
closed  and  the  stop-cock  B  opened,  a  vacuum  created  in  the  glass 
bottle  by  the  pump,  and  stop-cock  B  closed;  after  the  needle  has  been 
inserted  into  the  chest,  stop-cock  A  is  opened  and  the  fluid  in  the 
pleural  cavity  enters  the  bottle.  The  skin  and  needle  should  be  dis- 
infected, and  the  patient  placed  in  a  semi-recumbent  posture,  unless 
such  is  contraindicated.  Local  anesthesia  is  usually  unnecessary, 
although  it  is  desirable  to  give  a  little  whiskey  before  operation. 
The  puncture  is  generally  made  in  the  eighth  intercostal  space  near 


KESPIRATORV    SYSTEM 


615 


the  angle  of  the  scapula,  or  in  the  sixth  interspace  in  the  midaxillary 
Hne,  remembering  that  the  pleura  does  not  extend  as  low  in  children 
as  in  adults.  A  small  puncture  is  made  over  the  lower  rib  with  a 
knife,  and  the  skin  pulled  upwards,  so  that  the  needle,  guarded  by 
the  index  finger,  may  be  introduced  close  to  the  upper  edge  of  the  rib, 
in  order  to  avoid  the  intercostal  vessels;  thus  the  opening  is  valvular 
and  closes  as  soon  as  the  needle  is  withdrawn.  If  the  tap  be  dry,  a 
stylet  may  be  introduced  into  the  needle  to  make  sure  that  it  is  not 
plugged  and  if  fluid  still  fails  to  come,  the  needle  should  be  partly 
withdrawn,  and  reintroduced  at  a  different  angle.  The  fluid  is 
withdrawn  slowly,  and  the  flow  stopped  for  a  time  if  there  is  faint- 
ness,  violent  cough,  or  marked  alteration  in  the  pulse.  The  puncture 
in  the  skin  is  covered  with  collodion.  Although  it  is  true  that 
aspiration  will  occasionally  cure  empyema  it  is  generally  regarded 


Pig.  309. — -Aspirator. 

by  surgeons  as  an  exploratory  or  palliative  measure  or  as  a  prelimi- 
nary measure  to  permanent  drainage.  Thoracotomy  (opening  the 
pleural  cavity),  with  or  without  resection  of  a  rib,  is  the  means  of 
providing  more  or  less  permanent  drainage.  Thoracotomy  with- 
out resection  of  a  rib  is  indicated  when  the  patient's  condition  is 
very  serious,  as  it  is  easily  performed  under  local  anesthesia,  by 
making  an  incision  about  two  to  four  inches  in  length  along  the 
lower  border  of  the  seventh  or  eighth  intercostal  space  in  the  post- 
axillary  line.  A  small  opening  is  made  in  the  pleura,  in  order  to 
allow  the  pus  to  escape  slowly;  the  opening  is  then  enlarged,  loose 
pieces  of  lymph  removed,  and  a  short  rubber  tube  introduced.  The 
tube  should  be  sutured  to  the  skin,  to  prevent  its  expulsion,  and 
transfixed  with  a  large  safety  pin,  to  prevent  its  dropping  into 
the  cavity.  Resection  of  a  portion  of  a  rib  is  the  usual  operation,  as  it 
allows    more    room    for    exploration    and    free    drainage.     Ether 


6l6  MANUAL   OF   SURGERY 

is  contraindicated,  because  of  its  effect  on  the  lung.  The  best 
general  anesthetic  is  nitrous  oxid  and  oxygen,  but  chloroform  may- 
be employed,  local  anesthetic  is  the  method  preferred.  The  patient 
lies  on  his  back  or  as  suggested  by  Elsberg,  on  his  face  and  is 
brought  to  the  edge  of  the  table.  A  two  to  four  inch  incision, 
with  its  center  in  the  post  axillary  line,  is  made  over  the  seventh 
rib,  and  the  periosteum  divided  and  separated  from  the  entire 
circumference  of  the  rib  with  closed  curved  scissors  or  a  perios- 
teal elevator.  The  rib  is  divided  at  each  extremity  of  the  in- 
cision with  bone  forceps  and  removed,  the  intercostal  vessels 
having  been  pushed  aside  with  the  periosteum;  the  pleural  cavity 
is  opened  by  an  incision  through  reflected  periosteum  and  the 
operation  then  proceeds  as  in  thoracotomy  without  resection  of 
the  rib.  Irrigation  of  the  cavity  should  never  be  employed  in 
acute  cases  as  it  is  occasionally  followed  by  death.  In  chronic 
cases,  however,  and  in  those  which  the  adhesions  are  firm,  ir- 
rigation is  advisable.  The  tube  may  remain  in  place  until  the 
purulent  discharge  ceases,  or,  better,  it  may  be  removed  at  the  end 
of  a  week,  and  a  Bier  suction  pump  used  once  or  twice  daily  until 
the  lung  is  fully  expanded.  Moschcowitz  advocates  intercostal 
incision,  the  insertion  of  a  rubber  drainage  tube  having  a  cuff  of 
rubber  dam  which  lies  in  contact  with  the  skin  and  is  held  in  place 
with  adhesive  strips.  To  the  outer  end  of  this  tube  is  attached  a 
combination  instillation  and  suction  apparatus  by  means  of  a  Y  tube. 
At  first  hourly  and  later  second  hourly  instillations  of  Dakin's 
solution  are  employed.  After  six  or  seven  days  this  suction  ap- 
paratus is  removed  and  one  to  four  Carrel  tubes  inserted.  An 
additional  plain,  non  fenestrated  rubber  tube,  guarded  by  a  safety 
pin,  is  introduced  to  permit  of  a  free  escape  of  Dakin's  solution  and 
secretions.  The  same  technic  is  followed  as  in  all  infected  wounds, 
and  when  surgical  sterility  is  obtained  the  tubes  should  be  removed 
and  the  intercostal  wound  allowed  to  close.  If  the  sinus  persists 
(pleural  fistula),  there  is  caries  of  a  rib,  non-obliteration  of  the  cavity, 
pleuro  pulmonary  or  broncho  cutaneous  fistulae.  In  either  case  a 
secondary  operation  will  be  required.  If  the  lung  fails  to  reach  the 
chest  wall  after  several  months,  the  chest  wall  should  be  taken  to  the 
lung  by  thoracoplasty  (Estlander  of  Schede  operation).  One  may 
first  try,  however,  injections  of  Beck's  bismuth  paste  (see  Sinus). 
The  cavity  is  filled  with  mixture  No.  i  (not  more  than  loo  grams 
being  used)  and  the  opening  allowed  to  close.  If  the  temperature 
rises  above  ioi°  or  severe  pressure  symptoms  appear,  the  accumu- 
lated  fluid  is  evacuated  and  the  opening  again  allowed  to  close 


RESPIRATORY    S\STEM  617 

Repetition   of   the   injection   is  necessary  only  when   the  paste  is 
dischar<j;c(l  with  the  pus. 

Estlander's  operation  consists  of  the  resection  of  a  sufficient 
number  of  ribs,  with  the  periosteum,  to  obHterate  the  abscess 
cavity.  The  length  and  number  of  ribs  to  be  removed  depend  upon 
the  size  of  the  cavity.  In  a  large  cavity  it  may  be  necessary  to 
remove  three  or  four  inches  of  all  the  ribs  from  the  third  to  the  ninth. 
This  is  best  done  through  an  I-  or  U-  shaped  incision,  although 
separate  incisions  may  be  made  in  every  other  intercostal  space, 
and  the  rib  above  and  below  removed  through  each  incision.  The 
cavity  is  emptied  of  all  debris  and  packed  with  gauze. 

Schede's  operation  is  more  radical  and  more  severe.  A  U-shaped 
incision  is  made  from  the  origin  of  the  pectoralis  major  at  the  level  of 
the  axilla,  down  to  the  lower  level  of  the  pleural  cavity,  then  up  to  the 
level  of  the  second  rib  between  the  spine  and  the  scapula.  This 
flap  is  reflected  upwards,  and  all  the  ribs  over  the  cavity  from  the 
second  down,  and  from  their  tubercles  to  the  costal  cartilages, 
excised  together  with  the  periosteum,  intercostal  structures,  and 
thickened  parietal  pleura.  Bleeding  is  checked,  the  cavity  curetted 
with  gauze,  and  the  flap  sutured  so  as  to  lie  in  contact  with  the  lung, 
drainage  being  provided  by  sterile  gauze.  After  any  operation  for 
empyema  pulmonary  gymnastics  should  be  given  to  expand  the 
lung.  The  patient  should  also  have  been  informed  that  the  resulting 
deformity  is  necessary  to  the  cure. 

Pulmonary  decortication,  or  total  pleurectomy  {Fowler 's  operation) 
consists  in  excision  of  the  sinus,  resection  of  two  or  more  ribs,  and 
stripping  of  the  entire  pleura,  both  visceral  and  parietal,  from  the 
subjacent  parts,  thus  allowing  the  lung  to  expand.  The  flap  is 
replaced  and  the  cavity  drained.  Further  experience  is  needed  to 
determine  the  status  of  this  operation,  although  it  may  be  said 
that  at  least  partial  decortication  of  the  lung  is  a  useful  adjunct  to 
either  the  Estlander  or  the  Schede  operation.  Ransohoff  has 
recently  modified  this  operation  by  making  longitudinal  incisions  in 
the  pulmonary  pleura  {discission  of  the  lung). 

Pneumotomy,  or  incision  of  the  lung,  is  indicated  in  pulmonary 
gangrene  or  abscess,  echinococcus  cysts,  and  in  certain  cases  of 
bronchiectasis  and  foreign  bodies.  It  has  been  employed,  but  is 
rarely  justifiable,  for  tuberculous  cavities.  The  trouble  is  first 
localized  by  physical  examination,  the  X-ray,  and  by  the  aspirating 
needle.  The  needle  is  left  in  place  as  a  guide,  and  an  incision  made 
exposing  the  pleura.  More  room  may  be  obtained  by  resecting  the 
rib  above  and  below.     Often  the  pleura  will  be  adherent,  and  the 


6l8  MANUAL    OF    SURGERY 

cavity  may  be  at  once  opened  with  the  thermo-cautery  and  drained 
with  a  soft  rubber  tube.  Loose  particles  of  necrotic  tissue  are  re- 
moved, but  curettage  and  irrigation  should  be  avoided.  If  the 
layers  of  the  pleura  are  not  adherent,  they  may  be  sutured  together 
in  order  to  avoid  pneumothorax  and  infection  of  the  pleural  cavity, 
and  the  incision  into  the  lung  postponed  for  twenty-four  hours,  or 
longer  if  there  be  no  urgency.  The  positive  and  negative  pressure 
methods  for  preventing  pneumothorax  are  described  under 
pneumothorax. 

Pneumectomy,  or  excision  of  a  part  of  the  lung,  may  be  indicated 
in  pneumocele,  bronchiectasis,  pulmonary  neoplasms,  or  in  tumors  of 
the  chest  wall  which  have  invaded  the  superficial  portion  of  the  lung. 
The  operation  has  been  performed  for  tuberculosis  but  cannot  be 
recommended,  because  in  the  localized  form  recovery  frequently 
follows  medical  treatment,  and  in  the  dift'use  variety  the  disease 
cannot  be  removed.  The  measures  already  indicated  to  guard 
against  pneumothorax  should  be  taken,  the  base  of  the  affected 
portion  of  the  lung  surrounded  with  an  elastic  ligature  or  clamped, 
the  diseased  tissue  resected,  and  the  stump  sutured.  Any  bleeding 
points  that  remain  may  be  controlled  by  sutures,  ligatures,  the  cau- 
tery or  by  gauze  packing.  The  bronchial  stump  is  difficult  to  close 
satisfactorily.  ^Vlyer  crushes,  ligates,  and  invaginates  the  cut  end 
of  the  bronchus.  Garre  sutures  lung  tissue  over  it.  Giertz  suggests 
covering  it  with  a  free  transplant  of  fascia  lata. 

Pneumolysis  is  a  term  apphed  by  Friedrich  to  an  operation  which 
he  practises  for  unilateral  phthisis  pulmonaHs.  After  making  an 
incision  like  that  for  Schede's  operation,  the  ribs,  from  the  second  to 
the  tenth,  and  from  the  costal  cartilages  back  to  and  including  the 
heads,  are  removed  without  opening  the  pleura,  thus  allowing  the 
chest  wall  to  collapse,  putting  the  lung  at  rest,  and  favoring  cicatriza- 
tion of  the  cavities.  ]\Iurphy  has  injected  nitrogen  gas  into  the 
pleural  cavity  with  the  same  end  in  view.  Pneumolysis  is  still  in 
the  experimental  stage. 

In  addition  to  the  operations  mentioned  above  tuberculosis  of 
the  limg  has  been  treated  by  artificial  pneumothorax;  by  the  injec- 
tion of  antiseptics  into  the  tuberculous  cavity;  by  extrapleural 
tamponage,  i.e.,  compression  of  the  lung  by  means  of  paraffin  or 
fat  introduced  between  the  thoracic  wall  and  the  parietal  pleura; 
by  division  or  crushing  of  the  phrenic  nerve  or  the  intercostal  nerves; 
and  by  bilateral  chondrotomy  of  the  first  costal  cartilage,  which  is 
supposed  to  encourage  the  apices  of  the  lungs  to  expand. 

Bronchiectasis  has  been  treated  by  pneumotomy,  pneumectomy, 


RESPIRATORY    SYSTEM  619 

division  of  the  phrenic  nerve,  division  of  the  j^hrenic  nerve  with  sub- 
diaphragmatic transi)osition  of  the  lower  lobe  of  the  lung,  thoraco- 
plasty as  for  empyema,  pneumolysis,  compression  by  means  of  para- 
affin  or  fat  as  for  phthisis,  and,  in  order  to  induce  the  pulmonary 
tissue  to  shrink  by  ligation  of  the  artery  supplying  the  afifected  lobe. 
The  results  of  these  operations,  thus  far,  have  not  been  encouraging. 

Pulmonary  alveolar  emphysema,  according  to  Freund,  is  the 
result,  not  the  cause,  of  the  dilated,  rigid  thorax  characteristic  of 
this  disease.  He,  therefore,  excises  about  two  inches  of  the  ribs,  from 
the  second  to  the  sixth,  including  the  costochrondral  junctures,  with, 
he  states,  marked  benefit  in  some  cases. 

Pulmonary  abscess  is  comparatively  rare,  it  may  be  caused  by 
pneumonia,  penetrating  wounds,  foreign  bodies,  aspirated  foreign 
bodies  in  a  bronchus,  infection  of  a  haemorrhage  infarct,  rupture  into 
the  lung  of  a  neighboring  septic  focus,  septicemia  and  malignant 
growths.  The  symptoms  are  those  of  a  general  infection  and  there 
may  be  sudden  copious  expectoration  of  foul  smelling  pus  and 
subsequent  physical  signs  of  a  cavity. 

Treatment  may  require  pneumotomy  (see  page  617)  artificial 
neumothorax  has  been  used. 

Mediastinal  abscess  may  be  traumatic,  or  secondary  to  a  sup- 
purative process  in  the  neck  or  intrathoracic  organs.  The  symptoms 
are  those  of  sepsis  (except  in  chronic  cases),  and  pressure,  as  in 
aneurysm,  from  which  the  condition  may  be  distinguished  by  the 
absence  of  thrill,  bruit,  and  expansile  pulsation,  and  by  the  X-ray. 
In  doubtful  cases  a  fine  needle  may  be  introduced.  Various  tumors, 
both  benign  and  malignant,  may  originate  in  the  mediastinum  and 
produce  identical  pressure  symptoms.  Abscesses  should  be  drained 
after  localizing  them  with  the  aspirating  needle.  Tumors  are  for 
the  most  part  beyond  the  aid  of  present-day  surgery,  but  in  a  few 
instances  operative  relief  may  be  attempted.  The  anterior  medi- 
astinum may  be  approached  by  resecting  a  portion  of  the  sternum ; 
the  posterior  mediastinum  has  been  opened  extrapleurally  by  resect- 
ing the  ribs  near  the  spine.  The  possibility  of  removing  foreign 
bodies  impacted  in  the  thoracic  portion  of  the  esophagus,  as  well  as 
resecting  portions  of  the  gullet  for  malignant  disease,  is  presented  by 
the  latter  route. 


CHAPTER  XXV 
DISEASE  OF  THE  BREAST 

Congenital  malformations  such  as  absence  of  the  nipples  (athelia) 
incomplete  development  (micromazia)  or  absence  of  the  breasts 
(amazia),  and  supernumerary  nipples  (polythelia)  and  mammae 
(polymastia)  require  no  treatment. 

Retracted  nipples  may  be  congenital  or  due  to  contraction  from 
scar,  ulceration,  mastitis,  or  tumors.  Occasionally  the  condition 
may  be  benefited  by  repeatedly  drawing  the  nipple  out  with  the 
fingers  or  with  the  breast  pump.  Nursing  can  often  be  accomplished 
by  means  of  the  nipple  shield. 

Mammilitis,  or  inflammation  of  the  nipple,  is  almost  invariably 
associated  with  lactation,  the  delicate  epithelium  becoming  macer- 
ated by  milk  and  saliva,  and  easily  excoriated  (fissured  or  cracked 
nipples).  The  inflammation  may  extend  to  the  surrounding  skin, 
or  cause  an  abscess  of  the  breast  by  spreading  along  the  milk  ducts  or 
lymphatics;  occasionally  the  nipple  is  destroyed  by  ulceration. 
Nursing  is  painful  and  often  followed  by  bleeding,  hence  is  often 
postponed,  thus  leading  to  engorgement  of  the  breast.  The  treat- 
ment should  begin  before  the  trouble  is  inaugurated.  Towards  the 
end  of  pregnancy  the  epithelium  may  be  hardened  by  bathing  with 
alcohol,  during  lactation  the  nipples  should  be  washed  before  and 
and  after  nursing  with  boric  acid  solution,  and  carefully  dried.  If  a 
small  fissure  forms,  it  may  be  sprayed  with  peroxid  of  hydrogen,  washed 
with  boric  acid  solution,  dusted  with  boric  powder,  and  a  nipple 
shield  used  during  nursing.  In  the  more  severe  forms  the  child 
should  be  weaned,  the  secretion  of  milk  suppressed  by  the  applica- 
tion of  belladonna  ointment  and  a  pressure  bandage,  and  the  nipple 
treated  with  peroxid  of  hydrogen,  boric  acid  solution,  and  applications 
of  silver  nitrate. 

Paget's  disease  (malignant  dermatitis)  is  a  chronic  destructive 
inflammation  of  the  nipples,  usually  occurring  in  women  past  middle 
life.  Some  consider  certain  psorosperms  as  the  cause  of  this  condi- 
tion, but  such  has  not  been  proved.  At  first  there  is  a  moist  des- 
quamation, later  a  sticky  yellowish  discharge  with  the  formation  of 
crusts,  beneath  which  the  surface  is  red  and  raw.     The  nipple  may 

620 


DISEASES    OF   THE  BREAST  623 

circumscribed,  or  lobar  mastitis,  may  follow  trauma  or  pregnancy, 
but  is  most  frequent  in  women  approaching  the  menopause.  One 
or  more  of  the  lobes  become  enlarged,  indurated,  tender,  and  some- 
times the  seat  of  severe  neuralgia,  which  is  apt  to  be  worse  during 
menstruation.  The  condition  may  persist  for  months  or  years 
but  never  terminates  in  suppuration.  Chronic  diffuse,  lobular, 
or  interstitial  mastitis  may  occur  at  any  time  after  puberty,  but  is 
most  frequent  after  lactation  or  at  the  climacteric.  There  is  a 
marked  increase  in  the  connective  tissue,  which  ultimately  contracts, 
causing  induration,  shrinkage  of  the  breast,  depression  of  the  nipple, 
and  the  formation  of  cysts  owing  to  pressure  on  the  ducts,  pre- 
venting the  escape  of  degenerated  and  liquified  epithelium  which 
has  undergone  proliferation.  There  may  be  pain,  tenderness, 
and  a  watery  discharge  from  the  nipple.  The  disease  rarely  dis- 
appears, but  usually  terminates  in  atrophy  of  the  breast,  the  gland 
becoming  hard,  nodular,  and  shrunken,  or  in  general  cystic  degenera- 
tion or  possibly  carcinoma.  The  diagnosis  from  carcinoma  may 
be  difficult  or  even  impossible  without  microscopic  examination. 
The  involvement  of  the  opposite  breast,  the  absence  of  a  distinct 
tumor,  the  presence  of  small  cysts,  the  long  duration,  with  pres- 
ervation of  the  general  health,  and  without  infiltration  of  the 
perimammary  tissues  or  involvement  of  the  axillary  glands,  all 
point  to  interstitial  mastitis. 

The  treatment  of  the  above  forms  of  chronic  mastitis  is  the 
removal  of  any  source  of  irritation,  such  as  badly  fitting  corsets; 
support  by  a  bandage;  local  applications  of  belladonna  and  mercury; 
and  the  internal  administration  of  potassium  iodid,  If  there  be 
doubt  as  to  the  nature  of  the  condition,  if  there  be  a  diffuse  cystic 
change,  or  if  the  disease  cause  much  pain  or  anxiety,  the  breast 
should  be  amputated. 

Chronic  suppurative  mastitis  is  characterized  by  the  formation 
of  pus,  often  without  symptoms  of  inflammation;  it  follows  lactation, 
probably  as  the  result  of  infection  of  galactoceles,  or  it  may  be  due 
to  syphilis,  tuberculosis,  or  actinomycosis.  The  abscess  wall  is 
often  so  thick  as  to  resemble  a  tumor,  and  in  several  instances  the 
breast  has  been  removed  as  the  result  of  an  incorrect  diagnosis. 
A  hollow  needle  or  an  exploratory  incision  will  dispel  all  doubt. 
The  treatment  is  incision,  disinfection,  and  drainage,  or,  if  the  breast 
is  totally  destroyed,  amputation. 

Tuberculosis  of  the  breast  may  be  localized  {cold  abscess)  or 
diffuse,  but  is  not  common.  In  the  diffuse  form  the  breast  is  riddled 
with  sinuses  which  discharge   caseous  pus.     The  disease  may  be 


624  MANUAL   OF    SURGERY 

primary,  or  secondary  to  tuberculosis  of  neighboring  parts.  The 
treatment  of  the  diffuse  form  is  amputation  of  the  breast.  Sharply 
localized  disease  may  be  treated  by  excision,  or  by  incision  and 
curettage. 

Syphilititic  affections  of  the  breast  include  chancre,  mucous 
patches,  condylomata,  and  gummata,  the  appearances  and  treatment 
of  which  have  already  been  given. 

Tumors  of  the  breast  may  be  of  almost  any  variety,  but  only 
the  most  common  forms  require  special  description.  In  palpating 
a  breast  for  a  tumor,  the  gland  should  be  pressed  against  the  chest 
wall  with  the  flat  of  the  hand,  as  picking  up  the  tissues  between 
the  lingers  gives  a  deceptive  sense  of  a  new  growth. 


Fig.   311, — ^Round-celled  sarcoma  of  the  breast  which  had  broken  through  the  skin  and 
given  rise  to  repeated  hemorrhages. 

Fibroadenoma  is  the  most  common  benign  tumor  of  the  breast. 
Pure  adenoma  and  pure  fibroma  are  very  rare.  Fibroadenoma 
usually  originates  in  women  between  puberty  and  the  thirtieth  year. 
It  is  hard,  elastic,  slightly  nodular,  freely  movable,  generally  but 
not  always  painless,  and  unassociated  with  impairment  of  the  general 
health,  axillary  involvement,  or  retraction  of  the  nipple.  Cystic 
changes  occur  in  a  few  cases,  but  sarcomatous  or  carcinomatous 
degeneration  is  exceptional.  The  treatment  is  enucleation  of  the 
growth  from  its  capsule,  the  incision  radiating  from  the  nipple.  In 
order  to  conceal  the  scar,  Thomas  makes  the  incision  along  the 
lower  margin  of  the  breast,  which  is  then  turned  upward,  and  the 
growth  removed  from  behind  by  a  V-shaped  incision  that  is  sub- 


DISEASES    OF    THE  BREAST  625 

sequently  sutured.  If  Iho  growth  is  large  the  deformity  occasioned 
by  excision  may  be  avoided  by  filling  the  cavity  with  a  free  transplant 
of  fat,  taken  from  the  subcutaneous  tissues  of  the  buttock  or  abdomen. 

Cystadenoma,  or  adenocele,  the  acini  and  small  ducts  of  the 
adenomatous  tissue  dilate  and  form  cysts,  into  which  fibropapillo- 
matous  vegetations  project,  hence  the  terms  proliferous  mammary 
cyst,  intracanalicular  fibroma,  and  duct  papilloma  (the  last  term  is 
often  restricted  to  a  small  cyst  situated  near  the  nipple  and  con- 
taining a  warty  growth).  The  tumor  grows  slowly  but  may  attain 
a  large  size,  and  in  the  later  stages  adheres  to  the  skin  and  may 
even  break  through  it.  It  is  nodular,  encapsulated,  movable 
occurs  between  the  thirtieth  arid  fortieth  years,  is  generally  painless, 
and  may  be  associated  with  a  bloody  discharge  from  the  nipple,  as 
the  result  of  intracystic  hemorrhage.  It  is  hard,  but  varies  in 
consistency  according  to  the  size  of  the  cysts.  It  does  not  infiltrate 
the  surrounding  tissues  or  involve  the  axillary  glands.  Carcino- 
matous and  sarcomatous  degeneration  are  possibilities.  The 
treatment  in  the  early  stages  is  removal  of  the  growth  alone,  but  in 
the  later  stages  it  will  usually  be  necessary  to  amputate  the  breast 

Sarcoma  (Fig.  311)  constitutes  less  than  5  per  cent,  of  all  breast 
tumors;  the  cells  may  be  of  any  type,  authorities  differing  as  to 
whether  the  round-  or  the  spindle-celled  variety  is  the  most  frequent. 
Cyst  formation  occurs  in  about  half  the  cases,  as  the  result  of  hem- 
orrhage, degeneration,  or  obstruction  to  the  tubules  {cystosarcoma) . 
Adenosarcoma  is  that  form  which  develops  from  an  adenoma  or  a 
fibroadenoma,  or  in  which  the  tubules  and  acini  proliferate.  In- 
flammation and  suppuration  are  common  and  myxomatous,  fatty, 
calcareous,  and  telangiectatic  changes  may  occur.  Sarcoma  usually 
appears  between  the  ages  of  twenty-five  and  thirty,  grows  rapidly, 
is  encapsulated,  is  firm  or  soft  according  to  the  constituent  cell, 
causes  distention  of  the  overlying  veins,  and  does  not  involve  the 
axillary  glands  until  ulceration  has  occurred;  it  does,  however 
give  rise  to  early  metastases  in  the  viscera.  Pain  is  often  severe, 
and  discharge  from  the  nipple  frequent.  It  differs  from  carcinoma 
in  that  it  occurs  at  an  earlier  age,  is  more  movable,  grows  more 
rapidly,  is  less  uniform  in  consistency,  does  not  retract  the  nipple 
or  cause  enlargment  of  the  lymph  glands,  except  in  rare  cases,  and 
even  when  ulcerating  does  not  infiltrate  or  markedly  thicken  the 
skin.  The  prognosis  is  very  grave.  The  treatment  is  removal  of 
the  breast  and  the  axillary  glands. 

Carcinoma  constitutes  over  80  per  cent,  of  all  breast  tumors,  so 
that  any  lump  in  the  mammary  gland  must  be  regarded  as  malignant 

.      40 


626  MANUAL    OF    SURGERY 

unless  positive  proof  to  the  contrary  is  forthcoming.  It  attacks 
the  male  breast  in  about  one  per  cent,  of  the  cases.  The  influence 
of  heredity  is  probably  very  slight,  but  the  frequency  of  preceding 
trauma  or  inflammation  seems  to  be  more  than  a  coincidence. 
The  importance  of  Paget 's  disease  as  a  precancerous  condition  has 
already  been  mentioned.  Cancer  of  the  breast  is  said  to  be  more 
common  in  women  who  have  borne  children,  but  this  statement  is 
greatly  weakened  when  the  comparatively  small  number  of  nulliparae 
is  considered.  It  is  more  frequent  in  the  left  breast  than  in  the 
right,  and  is  usually  encountered  after  the  age  of  thirty-five,  although 
it  may  occur  at  a  much  earlier  period.  There  are  three  primary 
varieties,  viz.,  (i)  the  spheroidal-celled  or  acinous,  (2)  the  columnar 
celled  or  duct  cancer,  and  (3)  the  squamous-celled  or  epithelioma 
of  the  nipple,  (i)  The  acinous  form  may  be  (a)  medullary  (b) 
simple,  or  (c)  scirrhous.  Colloid  or  myxomatous  cancer  is  a  rare 
variety  in  which  one  of  the  former  has  undergone  mucoid  degenera- 
tion, (a)  Medullary,  encephaloid,  or  soft  cancer  is  soft  because 
the  epithelial  elements  predominate,  it  growls  rapidly,  increases  the 
size  of  the  breast,  quickly  ulcerates,  causes  early  metastases,  and 
appears  earlier  in  life;  as  a  rule  the  skin  is  distended  rather  than 
dimpled,  the  nipple  is  not  retracted,  and  the  areola  may  be  enlarged. 
The  growth  may  feel  hot,  owing  to  its  vascularity,  and  often  follows 
pregnancy,  it  is  sometimes  mistaken  for  mastitis  or  an  abscess, 
(b)  A  simple  cancer  approaches  the  normal  in  the  relative  amount 
of  fibrous  and  epithehal  tissues,  and  is  midway  between  the  encepha- 
loid and  the  scirrhous  in  hardness  and  malignancy,  (c)  The 
scirrhous  or  hard  cancer  which  is  the  most  frequent  variety  contains 
an  excess  of  fibrous  tissue  grows  more  slowly,  and  is  nodular  and 
of  a  stony  hardness;  it  infiltrates  the  glandular  tissue,  and  cannot 
be  moved  without  carrying  the  breast  with  it.  In  the  early  stages, 
with  the  breast  held  firmly,  the  tumor  may  be  moved  perpendicu- 
arly  to  but  not  parallel  with  the  milk  ducts.  Later  it  invades  the 
pectoral  muscle,  when  the  whole  breast  (not  the  tumor)  may  be 
moved  up  and  down,  but  not  in  the  direction  of  the  muscle  fibres; 
and  finally  it  adheres  to  the  chest  wall  and  becomes  absolutely  im- 
movable. Owing  to  the  contraction  of  the  fibrous  septa  of  the 
breast,  small  depressions  appear  in  the  skin,  which  has  been  likened 
to  pig's  skin,  or  the  rind  of  an  orange.  DimpHng  of  the  skin  may 
arise  from  a  scar  or  syphilis  and  may  not  be  obvious  unless  the 
gland  be  moved  to  and  fro  or  unless  the  skin  be  pushed  in  various 
directions.  The  growth  is  most  frequent  in  the  upper  and  outer 
segment  of  the  gland.     When  it  orginates  in  or  invades  the  tissues 


DISEASES    OF    THE   BREAST  627 

near  the  nipple,  the  nij)ple  is  retracted,  shrunken,  and  lixed,  and 
occasionally  exudes  a  thin  bloody  discharge.  Further,  owing  to 
the  contraction  of  the  growth,  the  nipple  often  occupies  a  higher 
position  than  the  one  on  the  normal  breast  and  the  areola  is  dimin- 
ished in  size  (Fig.  312).  Pain  is  absent  at  first,  but  in  the  final 
stages  becomes  agonizing  owing  to  involvement  of  the  axillary 
nerves.  Cachexia  also  is  a  late  symptom.  Ulceration  is  pre- 
ceded by  a  reddish  or  purplish  discoloration  of  the  skin.  A  scirrhous 
ulcer  is  deep  and  has  an  offensive  sanious  discharge,  a  sloughing 
base,  and  hard,  irregular,  everted  margins.  Extensive  infiltration 
of  the  skin  is  called  cancer  en  ciiirasse.  Occasionally  cysts  form, 
probably  as  the  result  of  obstruction  of  the  ducts.  The  axillary 
lymph  glands  are  enlarged  in  the  early  stages  and  probably  harbor 
cancer  cells  within  even  the  first  few  weeks.  Later  the  supra- 
clavicular glands  become  enlarged.     Pressure  on  the  axillary  vein 


Fig.  312. — The  nipple  in  scirrhus  of  the  breast  is  retracted,  shrunken,  fixed,  and  on 
a  higher  level  than  normal;  the  areola  is  smaller  than  normal  and  its  skin  fixed.  In 
inflammatory  troubles  of  the  breast  the  nipple  may  be  retracted  and  fixed,  but  the 
areola  may  be  larger  than  normal  and  on  a  lower  plane. 

and  lymph  vessels  causes  a  solid  edema  of  the  upper  extremity. 
When  the  IjTnphatics  running  to  the  axilla  are  blocked,  and  when 
the  grow^th  involves  the  sternal  half  of  the  gland  or  its  costal  surface, 
metastases  occur  in  the  chest,  the  lymph  from  the  inner  half  of  the 
gland  entering  the  anterior  mediastinum  through  the  second  and 
fourth  intercostal  spaces,  and  that  from  its  costal  surface  passing 
backwards  to  the  posterior  mediastinum.  Occasionally  the  opposite 
breast  and  the  glands  in  the  opposite  axilla  become  enlarged,  because 
of  the  free  lymphatic  anastomosis  across  the  middle  line.  A  scirrhus 
is  never  of  great  size,  and  occasionally  in  old  women  the  contracting 
fibrous  tissue  is  so  abundant  that  the  tumor  shrinks  rather  than 
enlarges  (atrophic  or  withering  scirrhus) ;  these  cases  may  last  for 
many  years.  An  ordinary  untreated  scirrhus  usually  causes  death 
in  from  two  to  three  years,  an  encephaloid  in  from  six  to  twelve 
months.  (2)  Duct  cancer  springs  from  the  duct  walls,  particularly 
in  cvstic  disease  of  the  breast,  but  is  not  common.     It  involves  the 


628  MANUAL    OF    SURGERY 

skin  and  lymph  glands  late,  and  is  softer  than  scirrhus.  There  is 
often  a  bloody  discharge  from  the  nipple.  (3)  Epithelioma  of  the 
nipple  presents  the  same  features  as  epithelioma  elsewhere;  it  is 
often  preceded  by  Paget 's  disease  of  the  nipple. 

The  treatment  is  amputation  of  the  breast  and  evacuation  of 
the  axilla  as  soon  as  the  growth  is  detected.  The  incision  of  the 
growth  to  confirm  a  diagnosis,  of  abscess  or  cyst  and  in  doubtful 
cases  to  obtain  a  section  for  rapid  microscopical  examination,  may 
be  advisable  before  a  radical  amputation.  Some  recognize  no  con- 
traindication to  operation  excepting  visceral  metastases,  and  remove 
portions  of  the  chest  wall  or  even  the  entire  upper  extremity.  Most 
surgeons  exclude  cases  of  cancer  en  cuirasse  and  those  in  which  there 
is  extensive  involvement  of  the  axilla  and  supraclavicular  glands. 
In  an  atrophic  scirrhus  in  an  old  woman  the  prognosis  may  be 
better  without  than  with  operation. 

Halsted's  operation  aims  to  remove  in 
one  piece  the  entire  breast  and  o\-erlying 
skin,  the  costal  portion  of  the  pectoralis 
major,  the  pectoralis  minor,  and  all  the 
fat  and  glands  of  the  axilla.  The  supra- 
clavicular glands  are  removed  in  a  second 
piece.  An  incision  (Fig.  313)  is  carried 
through  the  skin  and  fat,  and  the  triangular 
flap  ABC  turned  back.  The  costal  por- 
tion of  the  pectoralis  major  is  divided  close 
Fig.  313.— (Binnie.)         ^^  ^-^^  ^^^^  ^^^  Separated  from  the  clavicular 

portion,  which  with  the  overlying  skin  is  divided  up  to  the  clavicle, 
exposing  the  apex  of  the  axilla;  these  flaps  are  drawn  upwards  with 
a  retractor  and  separated  from  the  underlying  tissues,  and  the 
muscle  further  spht  as  far  as  the  humerus,  where  it  is  severed  close 
to  the  bone.  The  breast,  pectoralis  major,  and  all  fat  are  stripped 
from  the  chest  wall,  including  the  pectoralis  minor,  which  is  divided 
at  each  end,  thus  exposing  the  entire  axilla,  which  is  cleansed  of 
fat  and  lym.phatic  glands  from  above  and  within,  downwards  and 
outwards,  all  small  vessels  being  ligated  close  to  the  axillary  vessels, 
which,  with  the  nerves,  should  alone  remain.  The  triangular 
flap  of  skin  is  drawn  outwards  and  the  lateral  and  posterior  walls 
of  the  axilla  likewise  cleared,  the  subscapular  vessels  being  ligated, 
and  the  subscapular  nerves  preserved  if  possible.  The  mass  is 
then  turned  inward,  and  removed  from  the  chest  by  cutting  from 
B  to  C.  A  vertical  incision  is  now  made  along  the  posterior  margin 
of  the  sternomastoid,  and  the  supra-  and  infra-clavicular  fat  and 
glands  removed  by  dissecting  from   the  junction  of  the  internal 


DISEASES    OF    THE   r3REAST  629 

jugular  and  subclavian  veins  downwards  and  outwards.  The 
cervical  wound  is  sutured,  and  the  edges  of  the  chest  wound  approxi- 
mated by  a  buried  purse-string  suture  of  silk,  which  includes  the 
base  of  the  triangular  llap,  the  apex  being  spread  over  the  axilla. 
The  rest  of  the  wound  is  covered  with  Thiersch 's  sking  grafts.  The 
axilla  is  not  drained.  The  disability  resulting  after  such  an  exten- 
sive operation  is  surprisingly  slight. 

The  authors  operation,  to  quote  from  the  Transactions  of  the 
American  Surgical  Association,  1915,  "embodies  the  principles  laid 
down  by  Halstead,  with  the  following:  The  axilla  is  attacked  first 
to  determine  the  extent  of  the  lymphatic  involvement  and  the  feasi- 
bility of'  radical  treatment  (Gross) ;  to  secure,  once  for  all,  at  their 
origin,  the  blood  vessels  supplying  the  breast,  thus  minimizing  hemor- 
rhage, economizing  time,  and  preventing  shock  (]\Ieyer);  to  suppress 
Umphatic  drainage  as  early  as  possible  and  prevent  neoplastic 
dissemination  (Gerster) ;  and  to  leave  the  breast  as  a  warm  covering 
for  the  thorax  until  the  final  stage  of  the  operation.  The  incision 
permits  free  exposure,  including  the  subscapular  space,  which  is 
sometimes  neglected;  does  not  run  onto  the  arm  or  through  the 
axilla,  in  which  situations  a  contracting  scar  may  interfere  wdth  the 
functions  of  the  arm  or  press  on  the  blood  vessels  and  the  nerves 
and,  with  extensive  undermining,  can  almost  always  be  closed. 
When  primary  closure  cannot  be  obtained  the  raw  surface  is  covered 
with  pedunculated  flaps  from  the  abdomen  and  the  back.  Owing 
to  the  situation  of  the  incision  a  second  opening  is  not  needed  for 
drainage,  and  the  dressing  of  the  wound  is  simplified.  The  drain, 
when  employed  for  lymphorrhea,  is  removed  at  the  end  of  two  days, 
and  never  replaced.  Leaving  the  w^ound  open  and  prolonged  drain- 
age mean  infection  and  much  fibrous  tissue.  An  incision,  skirting 
the  upper  margin  of  the  breast,  is  made  from  a  point  on  the  edge  of 
the  sternum  farthest  from  the  growth  and  on  a  level  with  the  nipple, 
to  a  point  on  the  same  level  at  the  posterior  axillary  fold  (Fig.  314). 
The  skin  is  undermined  from  the  incision  to  the  clavicle  and  the 
head  of  the  humerus,  and  from  the  sternum  to  the  posterior  axillary 
fold.  The  clavicular  is  separated  from  the  costal  portion  of  the 
pectoralis  major,  and  the  tendon  of  the  latter  severed  close  to  the 
humerus.  The  costocoracoid  membrane  is  divided  and  the  pector- 
alis minor  cut  at  its  point  of  insertion.  With  a  self  retaining  retrac- 
tor, and  a  smaller  retractor  held  by  an  assistant,  the  entire  axilla  is 
exposed  for  evacuation  (Fig.  315),  which  progresses  from  above  and 
within,  downward  and  outward.  The  vessels  supplying  the  breast 
are  divided  between  ligatures.  The  subscapular  vessels  are  tied  at 
each  end  and,  with  the  environing  areolar  tissue,  pushed  toward  the 


630 


MANUAL   OF    SURGERY 


Fig.  314. — Amputation  of  the  breast;  primary  incision.     The  towels  which  should  be 
attached  to  the  margins  of  the  wound  are  not  shown. 


Fig.  315. — Amputation  of  the  breast;  dissection  06  axilla. 


DISEASES    OF   THE   BREAST 


631 


median  line,  thus  laying  bare  the  latissimus  dorsi,  teres  major,  sub- 
scapularis,  and  serratus  magnus.  The  ends  of  the  original  incision 
are  joined  by  a  cut  which  skirts  the  inferior  margin  of  the  breast 
(Fig.  316),  and  the  skin  undermined  to  the  level  of  the  lowest  portion 
of  the  costal  arch,  or  even  lower.  Through  this  incision  one  may 
remove,  as  suggested  by  Hanley,  the  deep  fascia  over  the  upper 
portion  of  the  abdominal  muscles;  we  have  not  adopted  this  pro- 
cedure as  a  routine  measure.  Next  the  breast  is  turned  toward  the 
opposite  side  of  the  body,  the  origin  of  the  pectoralis  minor  cut,  the 
perforating  vessels  seized  before  division,  and  the  mass  removed  by 


Fig.  316. — Amputation  of  the  breast;  the  lower  incision  is  made  after  evacuation  of  the 

axilla. 


severing  the  costal  origin  of  the  pectorahs  major.  The  wound  is 
irrigated  with  hot  salt  solution,  and  closed  with  several  combined 
retention  and  coaptation  sutures  of  silkworm  gut  (Fig.  69),  and  a 
continuous  suture  of  celluloid  thread,  except  at  the  axillary  end 
where  one  suture  is  left  untied,  to  provide  an  exit  for  a  gauze  drain 
(Fig.  317),  which  is  removed  in  forty-eight  hours  and  the  suture  tied. 
The  arm  is  not  bandaged,  and  the  patient  is  allowed  to  put  it  into 
any  position  she  desires.  Edema  of  the  arm  immediately  following 
operation  we  regard  as  a  favorable  sign;  it  indicates  that  the  opera- 
tion has  been  thorough,  that  all  the  lymphatic  structures  in  the 
axilla  have  been  removed,  and  the  lymphatic  drainage  of  the  arm 


632 


MANUAL    OF    SURGERY 


completely  interrupted.  It  usually  disappears  in  from  two  to  four 
months,  but  may  last  longer,  and  indeed  be  permanent.  Edema 
appearing  after  an  interval  is  due  to  pressure  on  the  axillary  vein  by 
a  cicatrix,  by  a  recurrent  growth;  to  a  neoplastic  invasion  of  the 
vein;  to  venous  thrombosis;  to  a  tardy  lymphangitis  or  lymphthrom- 
bosis;  hence  is  not  always,  as  is  sometimes  thought,  a  premonitory 
sign  of  early  dissolution."  Suggestions  for  the  treatment  of  lymph- 
edema will  be  found  under  lymphedema,  chap,  xvi;  for  inoper- 
able carcinoma  under  carcinoma,  chap.  xiii.  The  mortality  of 
the  modern  breast  amputation  is  less  than  3  per  cent.     The  percent- 


^w;tA&5'f^^/6,45^'5^: 


Fig.  317. — Amputation  of  the  breast ;"woundtclosed. 

age  of  permanent  cures,  i.e.,  after  three  years,  is  about  20  per  cent. 
In  over  half  of  the  cases  the  return  of  the  disease  is  not  a  local  recurrence 
but  a  metastasis.  The  order  of  the  frequency  of  metastasis  is  lungs 
liver,  bones,  especially  vertebrae,  and  upper  part  of  femora.  The 
X-ray  is  of  distinct  value  in  diagnosing  bone  metastisis  before  opera- 
tion and  of  therapeutic  value  after  operation.  Skeletal  metastasis 
of  carcinoma  may  be  very  slow  in  their  development.  It  may  take 
years  before  clinical  symptoms  present. 

Cysts  of  the  breast  are  to  be  distinguished  from  cystic  degenera- 
tions, which  may  occur  in  any  form  of  mammary  tumor,  but  parti- 
cularly in  sarcoma  and  cystadenoma. 


DISEASES    OF    THE   BREAST 


633 


Acinous  or  retention  cysts  are  caused  by  blocking  of  the  ducts 
and  pressure  upon  them  will  often  cause  a  discharge  from  the  nipple. 
Such  cysts,  when  occurring  during  the  nursing  period,  contain  milk 
(galatocele) .  A  milk  or  lacteal  cyst  is  round,  situated  near  the  nipple 
and  usually  painless;  it  iluctuates,  except  in  old  cases  in  which  the 
wall  is  thick  or  the  contents  solid.  The  treatment  is  excision.  In- 
volutwn  cysts  {cystic  degeneration  of  the  breast)  occur  in  the  course  of 
interstitial  mastitis,  or  after  the  menopause  when  the  breast  is 
undergoing  degenerative  changes.  They  are  small  and  numerous, 
and  may  contain  intracystic  fibropapillomatous  vegetations     Both 


Fig.  317a. — Edema    rollowing  breast  amputation   caused  by  pressure  of  cicatrix  on 

axillary  vein. 

glands   are   usually  affected.     The  treatment  is  amputation  of  the 
breast,  because  of  the  danger  of  carcinoma. 

Interacinous  cysts  are  unconnected  with  the  ducts,  do  not  cause 
a  discharge  from  the  nipple,  contain  no  intracystic  growths,  and  are 
lined  with  endothelium  instead  of  epithelium.  They  contain  serum, 
and  are  supposed  to  originate  from  the  lymph  spaces.  They  may 
be  single  or  multiple.  The  diagnosis  may  be  made  in  doubtful  cases 
by  the  use  of  the  exploring  needle.  The  treatment  is  excision  of  the 
cyst.  Hydatid  and  dermoid  cysts  also  occur  in  the  breast,  but  are 
rare,  and  are  treated  by  excision. 


CHAPTER  XXVI 

UPPER  DIGESTIVE  APPARATUS 

THE  LIPS 

Hare-lip  is  a  congenital  cleft  in  the  upper  lip  due  to  non-union  of 
the  frontonasal  and  superior  maxillary  processes  (p.  570).  The  term 
is  misleading,  as  the  cleft  is  not  central  as  in  a  hare's  lip,  although  a 
median  hare-lip  is  a  possibility.  Hare-lip  may  be  single  or  double, 
incomplete  or  complete,  and  it  may  or  may  not  be  associated  with 
cleft  palate  (Fig.  318).  It  is  more  frequent  on  the  left  side,  more 
common  in  males,  and  is  sometimes  hereditary.     When  double,  the 


Pig.  318.- 


-Hare-lip  and  cleft  palate.     The  nasal  septum  is  fused  with  the  right  palatine 
process.     Note  the  width  of  the  face. 


intermaxillary  bones  often  fail  to  unite  and,  with  the  central  portion 
of  the  lip,  project  forward.  In  all  cases  the  nose  is  broadened  and 
flattened. 

The  best  time  for  operation  is  between  the  third  and  sixth  months 
of  life,  i.e.,  before  dentition  begins.  The  principles  of  any  operation 
for  hare-lip  are  to  pare  the  edges  of  the  cleft,  bring  the  flaps  together 
without  tension  by  separating  the  lip  from  the  gum,  and  to  have  the 
Vermillion  of  the  lip  in  alignment  and  a  little  projection  at  the  edge 
formerly  occupied  by  the  gap.  The  suture  material  is  usually  silk- 
worm gut,  introduced  through  the  entire  thickness  of  the  lip,  and 
removed  at  the  end  of  two  weeks.  In  order  to  avoid  the  scarring  of 
stitches,  chromicized  catgut,  passed  through  all  the  tissues  except 

634 


UPPER   DIGESTIVE    APPARATUS 


63: 


the  skin  and  tied  within  the  month,  may  be  employed,  an  additional 
subcuticular  stitch  being  used  if  necessary.  In  order  to  prevent 
aspiration  of  blood,  the  patient  should  be  placed  in  the  Trendelen- 
burg posture.,  or  on  the  back  with  the  head  hanging  over  the  end  of 


Fig.  319.  Fig.  320. 

Figs.  319  and  320 — Ma'.gaigne     (Esmarch  and  Kowalzig.) 

the  table  (Rose's  position).  No  dressing  need  be  applied  to  the 
wound,  although  some  surgeons  prefer  to  use  collodion.  Some 
measures,  such  as  splinting  the  elbow  joint,  should  be  employed  to 
prevent   disturbance   of   the   wound   by   the   child's   lingers.     The 


Fig.  321.  Fig.  322. 

Pigs.  321  and  322 — Nelaton.     (Esmarch  and  Kowalzig.) 

child  is  fed  with  a  spoon  or  medicine  dropper,  until  able  to  return  to 
the  breast.  Figs.  319  to  324  illustrate  various  operations  for  incom- 
plete hare-lip,  and  Figs.  325  to  ^35  operations  for  complete  single 
hare-lip.     Operations   for  double  uncomplicated  hare-lip  are  illus- 


Fig.  323.  Fig.  324. 

Figs.  323  and  324 — Mirault.     (Esmarch  and  Kowalzig.) 

trated  in  Figs.  336  to  344.  Double  hare-lip  complicated  by  protru- 
sion of  the  intermaxillary  bone  must  be  treated  by  removing  or 
replacing  the  projecting  bone,  the  soft  parts  being  united  by  one  of 
the  methods  previously  indicated.     Excision  alters  the  contour  of 


636 


MANUAL    OF    SURGERY 


the  face  and  removes  the  central  incisor  teeth;  reposition  may  be 
followed  by  necrosis,  non-union,  or  backward  eruption  of  the  teeth; 
hence  judgment  is  required  in  individual  cases  in  deciding  whether 
or  not  the  bone  should  be  removed.     It  may  be  stated  however  that 


Fig.  325.  Fig.  326. 

Figs.  325  and  326. — CoUis'  operation.     (Binnie.) 

a  rudimentary  bone  attached  to  the  tip  of  the  nose  should  be  excised, 
and  that  one  which  projects  but  slightly  should  be  bent  back  into 
position. 


Fig.  327.  Fig.  328.  Fig.  329. 

Figs.  327  to  329. — Giraldes.     (Esmarch  and  Kowalzig.) 

Oblique  facial  cleft,  running  from  the  lower  hd  to  the  mouth,  and 
resulting  from  non-closure  of  the  naso-orbital  fissure,  is  a  rare 
deformity.  Cleft  of  the  lower  lip  or  lower  jaw  is  very  rare,  and 
due  to  non-union  of  the  mandibular  processes  in  the  middle  hne. 


Fig.  330.  Fig.  331.  Fig.  332. 

Figs.  330  to  332. — Konig.     (Esmarch  and  Kowalzig.) 

Macrostoma,  or  enlarged  mouth,  is  due  to  defective  union  of  the 
maxillary  and  mandibular  processes;  microstoma,  or  small  mouth, 
to  excessive  fusion  of  these  processes.  All  these  conditions  may  be 
remedied  by  plastic  operations. 


UPPER   DIGESTIVE   APPARATUS 


637 


Cracked  or  chapped  lips,  the  results  of  cold,  and  herpes  labialis, 
or  fever  blisters,  are  treated  by  the  application  of  cold  cream,  or  better 
a  strong  solution  of  silver  nitrate.     Cracks  and  fissures  radiating  from 


Fig-  333-  Pig.  334-  Fig.  335. 

Figs.  333  to  335. — (Esmarch  and  Kowalzig.) 


Fig.  336.  Fig.  337.  Fig.  338. 

Figs.  336  to'338. — Maas.      (Esmarch  and  Kowalzig.) 


Fig.  339.  Fig.  340.  Pig.  341. 

Figs.  339  to  341. — Hagedorn.     (Esmarch  and  Kowalzig.) 


Fig.  342.  Fig.  343.  Fig.  344. 

Figs.   342  to  344. —  (Esmarch  and  Kowalzig.) 

the  angles  of  the  mouth  are  due  to  congenital  syphihs.     Chancre, 

mucous  patches,  and  tuberculous  ulcers  also  may  occur  on  the  Hps. 

Macrocheilia,  or  hypertrophy  of  the  lip,  usually  the  lower,  may  be 

due  to  lymph angiectasis,  tertiary  syphilis,  or  a  tuberculous  predis- 


638 


MANUAL    OF    SURGERY 


position  (strumous  lip).  If  excessive,  a  horizontal  wedge  of  mucous 
membrane  and  submucous  tissue  may  be  exercised.  Mucous  cysts 
appear  as  rounded,  translucent  swellings.  They  are  caused  by 
blocking  of  the  orifices  of  the  glands,  and  are  treated  by  excision. 
Warts,  horns,  and  nevi  also  may  be  seen  on  the  lips. 


Fig.   345. — Epithelioma  of  lip. 


Pig.    346. — Dowd's  operation.      (Binnie.) 


Epithelioma  almost  invariably  attacks  the  lower  lip,  and  is  seldom 
seen  in  women.  The  irritation  of  a  short  clay  pipe  is  responsible 
for  some  cases.  It  begins  as  a  small  fissure,  infiltration,  or  warty 
growth,  which  ulcerates  and  is  covered  by  a  scab  (Fig.  345).  The 
ulcer  slowly  spreads,  is  situated  on  a  hard  base,  and  ultimately 
invades  the  jaw.     Sooner  or  later  the  cervical  glands  are  involved. 


Fig.  347.  Fig.  348. 

Figs.   347  and  348. — Bruns.      (Esmarch  and  Kowalzig.) 

but  visceral  metastases  are  uncommon.     In  old  men  the  disease  is 
often  very  slow,  and  may  not  cause  death  for  a  number  of  years. 

The  treatment  is  early  and  thorough  excision,  wdth  the  glands  in 
the  submaxillary  and  submental  triangles.  Permanent  cure  may  be 
obtained  in  from  50  to  60  per  cent,  of  the  cases  thus  treated.  All 
incisions  should  be  at  least  a  half  inch  away  from  the  growth.     Small 


UPPER   DIGESTIVE    APPARATUS 


639 


Fig.  349 


Fig.  350. 


Figs.  349  and  350.— Estlander.     (Esmarch  and  Kowalzig.) 


Fig.  351 


Fig.  352. 


Figs.  351  and  352.— Dieffenbach.     (Esmarch  and  Kowalzig.) 


Fig.  353 


Fig.  354- 


Figs.  353  and  354.— Blasius.     (Esmarch  and  Kowalzig.) 


rIG.     353.  ,     ■      N 

Figs.  355  and  356.— Langenbeck.     (Esmarch  and  Kowalzig.) 


640  MANUAL    OF    SURGERY 

growths  may  be  excised  by  the  classical  \'-shaped  incision,  and  the 
glands  removed  from  both  sides  of  the  neck  by  separate  incisions. 
In  larger  growths  Dowd's  operation  (Fig.  346)  may  be  employed. 
The  cervical  incisions  are  made  first,  in  order  to  remove  the  fat, 
lymph  glands,  and  submaxillary  saHvary  glands  before  opening  the 
mouth.  The  incisions,  I  E  and  G  K,  sufficiently  long  for  approxima- 
tion of  the  flaps,  are  made  by  dividing  the  skin  about  one-third  inch 
lower  than  the  mucous  membrane,  so  that  the  latter  may  be  stitched 
to  the  skin  of  the  new  lower  lip.  The  edges  E  A  and  G  C  are  ap- 
proximated after  excising  wedged-shaped  pieces  of  skin  at  L  and  M. 
Figs.  347  to  356  show  other  methods  of  cheiloplasty. 

THE  SALIVARY  GLANDS 

Parotitis  is  most  often  seen  as  mumps,  an  acute,  contagious, 
self-limited,  specific  inflammation,  which  may  involve  also  the 
submaxillary  and  sublingual  glands.  Suppuration  is  rare,  but  meta- 
stasis to  the  testes,  ovaries,  or  mammae  may  occur.  A  true  orchitis  is 
produced  in  the  testicle,  which  usually  undergoes  subsequent  atro- 
phy; the  condition  is  generally  unilateral,  however,  and  steriUty 
does  not  follow.  A  nonsuppurative  parotitis  may  follow  also  injury, 
salivary  calcuh,  and  disease  or  injury  of  the  abdomen.  The  symp- 
toms are  pain  and  swelling,  with  perhaps  some  elevation  of  tempera- 
ture. The  treatment  is  the  application  of  ichthyol  or  belladonna 
ointment,  and  an  antiseptic  mouth  wash,  as  oral  sepsis  is  a  factor  in 
many  cases. 

Suppurative  parotitis  rarely  follows  the  forms  described  above 
but  is  commonly  the  result  of  pyemia  or  one  of  the  acute  infectious 
fevers.  In  addition  to  the  swelling,  and  the  redness  and  edema  of 
the  skin,  pain  and  constitutional  symptoms  are  usually  severe,  owing 
to  the  firmness  of  the  surrounding  fascia.  This  fact  explains  also  the' 
tendency  of  the  pus  to  burrow  deeply  into  the  surrounding  tissues 
rather  than  point  externally.  The  treatment  is  incision  parallel  with 
the  fibers  of  the  facial  nerve  and  in  front  of  the  line  for  the  external 
carotid. 

Mikulicz's  disease  is  a  chronic  s}Tiimetrical  enlargement  of  all  of 
the  salivary  glands  and  of  the  lachrjTnal  glands,  the  nature  of  which 
is  not  clearly  understood.  It  is  sometimes  congenital,  sometimes 
associated  with  gout,  syphilis,  tuberculosis,  or  leukemia.  There  is 
neither  pain  nor  tenderness,  but  there  may  be  interference  with 
speech  and  mastication  and  considerable  deformity.  Some  benefit 
may  follow  the  administration  of  arsenic  and  the  iodids. 


UPPER   DIGESTIVE    APPARATUS  64 1 

Salivary  calculi  consist  of  carbonate  and  phosphate  of  lime,  and 
may  form  in  any  of  the  ducts.  The  symptoms  are  those  of  obstruc- 
tion to  the  flow  of  saliva,  which  may  be  caused  likewise  by  cicatrices, 
tumors,  etc.  There  arc  swelling  and  tenderness  of  the  gland  during 
meals,  and  in  old  cases  a  permanent  thickening  of  the  glandular 
tissues.  The  calculus  may  be  detected  with  the  finger,  probe,  needle, 
or  X-ray.  It  may  be  removed  by  dilating  the  duct,  by  incision  from 
within  the  mouth,  or,  in  large  calculi  in  the  submaxillary,  by  removal 
of  the  gland. 

Ranula  is  a  cystic  tumor  due  to  obstruction  of  one  of  the  ducts  of 
the  subhngual  glands,  or  more  rarely  the  duct  of  the  submaxillary 
gland.  It  contains  a  mixture  of  mucus  and  saliva.  Similar  in 
nature  are  the  mucous  cysts  which  may  form  on  the  floor  of  the 
mouth  as  the  result  of  obstruction  to  the  ducts  of  the  mucous  glands. 
Dermoid  cysts  in  this  region  frequently  spring  from  the  thyroglossal 
duct,  hence  are  situated  in  the  median  line  and  often  cause  a  swelling 
beneath  the  chin.  The  treatment  of  ranulas  and  mucous  cysts  is 
removal  of  the  anterior  wall  and  cauterization  of  the  posterior  wall, 
so  that  the  cavity  will  be  filled  by  granulations.  In  some  cases  cure 
can  be  obtained  only  by  dissecting  out  the  entire  cyst  and  removing 
the  salivary  gland.  Dermoid  cysts  require  an  external  incision  and 
careful  dissection. 

Tumors  of  the  parotid  gland  are  usually  of  a  mixed  nature.  A 
benign  parotid  tumor  is  usually  a  mixture  of  chondroma,  fibroma, 
myxoma,  and  adenoma,  hence  it  is  hard  and  nodular  in  certain  parts 
and  soft  in  others.  It  grows  very  slowly,  and  is  usually  superficial 
to  the  important  vessels  and  nerves,  except  in  the  later  stages.  A 
malignant  parotid  tumor  may  be  sarcoma,  carcinoma,  or  endothe- 
lioma. It  is  often  the  result  of  a  malignant  change  in  a  benign 
tumor,  from  which  it  may  be  distinguished  by  its  immobility,  greater 
pain  and  rapidity  of  growth,  more  frequent  association  with  facial 
paralysis,  and  by  its  tendenc}"  to  enlarge  the  lymph  glands.  The 
lymph  gland  lying  near  the  surface  of  the  parotid  may  enlarge  as  the 
result  of  inflammation,  tuberculosis,  or  a  neoplastic  change;  it  is 
distinguished  from  a  parotid  tumor  by  its  uniform  consistency  and 
its  more  superficial  situation. 

The  treatment  is  excision.  Benign  tumors  may  be  enucleated 
through  an  incision  parallel  with  the  course  of  the  facial  nerve. 
Malignant  tumors  require  removal  of  the  entire  gland  through  a 
vertical  incision,  supplemented,  if  need  be,  by  a  transverse  cut 
running  forwards  from  the  middle  or  lower  end.  The  dissection 
should  proceed  from  below  upwards,  so  that  the  external  carotid 


642  MANUAL    OF    SURGERY 

artery  may  be  ligated  in  the  early  part  of  the  operation.  The  facial 
nerve  is,  of  course,  destroyed,  and  of  this  the  patient  should  be 
previously  warned.  The  operation  is  very  difficult  and  recurrence 
almost  inevitable.  Somewhat  similar  tumors  are  encountered  in  the 
other  salivary  glands,  but  such  are  much  more  easily  excised. 

Salivary  fistula  is  usually  caused  by  disease  or  injury  of  Steno's 
duct,  which  is  about  one-eighth  inch  in  diameter,  opens  into  the 
mouth  opposite  the  second  upper  molar  tooth,  and  is  represented  by  a 
line  drawn  from  the  lowest  part  of  the  cartilage  of  the  ear  to  a  point 
midway  between  the  angle  of  the  mouth  and  the  ala  nasi.  If  small, 
the  fistula  may  sometimes  be  closed  by  cauterization  or  by  sutures, 
first  dilating  any  existing  stricture  in  the  distal  portion  of  the  duct. 
If  this  method  fails  or  if  the  distal  portion  of  the  duct  is  obliterated, 
the  central  portion  may  be  isolated,  and  its  orifice  sutured  to  the 
mucous  membrane  of  the  mouth,  the  external  wound  being  closed. 
Some  surgeons  make  an  opening  from  the  fistula  into  the  mouth,  and 


Fig.   357. — Braun's  operation.      (Binnie.) 

keep  this  opening  patent  by  a  rubber  tube  or  seton.  until  it  is  lined 
with  epithelium;  the  external  opening  is  then  closed.  When  the 
fistula  is  near  the  gland,  a  new  duct  may  be  constructed  from  the 
mucous  membrane  as  shown  in  Fig.  357.  Jianu  cut  the  facial  vein 
at  two  different  points,  anastomosed  the  posterior  end  of  the  isolated 
venous  segment  with  Steno's  duct,  and  the  anterior  end  with  the 
mucous  membrane  of  the  mouth.  Ferrarini  suggests  anastomosing 
the  parotid  with  the  submaxillary  gland.  When  all  other  forms  of 
treatment  fail,  the  nerve  of  secretion  (auriculo-temporal)  may  be 
avulsed,  or  the  gland  removed  (Leriche). 

THE  TONGUE 

Malformations,  such  as  bifid  tongue,  hemiatrophy,  and  total 
absence  of  the  tongue,  are  very  rare.  Tongue-tie,  or  shortness  of  the 
frenum,  may  interfere  with  sucking  and  later  cause  lisping;  the 
frenum  may  be  nicked  with  a  pair  of  blunt  scissors,  and  if  this  does 
not  produce  sufficient  mobilization,  the  rest  of  the  frenum  may 
be   torn  with   the  finger,   thus  avoiding  troublesome  hemorrhage. 


UPPER   DIGESTIVE    APPARATUS  643 

The  iVcmini  ma)-  he  ahnorniall}'  lon*^  and  allow  the  l()n[i;ue  t-o  fall 
hackwards  and  interfere  with  resj)irati()n.  A)ikyloglossia,  in  which 
the  tongue  is  adherent  to  the  iloor  of  the  mouth,  may  be  congenital  or 
follow  ulceration  in  this  region.  The  adhesions  should  be  separated, 
a  procedure  which  may  be  very  difficult  in  acquired  cases.  Macro- 
glossia,  or  elephantiasis  of  the  tongue,  is  usually  congenital,  and  is  due 
to  an  increase  in  the  connective  tissue  and  lymphangiectasis.  Lym- 
phatic cysts  and  hypertrophied  papillx'  may  be  seen  on  the  surface 
and  recurring  glossitis  augments  the  volume  of  the  organ.  The 
tongue  protrudes  from  the  mouth,  becomes  indurated  and  purpUsh. 
interferes  with  speech  and  swallowing,  and  causes  deformity  of  the 
teeth  and  jaws.  The  treatment  is  removal  of  a  wedge-shaped 
portion.  Enlargement  of  the  tongue  may  be  caused  also  by  stomati- 
tis particularly  the  syphilitic  variety,  and  is  seen  in  acromegaly  and 
sometimes  in  idiots. 

Wounds  of  the  tongue  are  seldom  serious,  although  in  a  few  cases 
death  from  hemorrhage  has  followed.  Sutures  should  be  of  silk,  as 
the  moisture  and  movements  of  the  tongue  will  quickly  loosen  cat- 
gut. Ordinarily  bleeding  is  controlled  by  closure  of  the  wound, 
although  if  the  ranine  artery  is  opened  a  hgature  may  be  necessary. 

Acute  parenchymatous  glossitis  is  caused  by  infection  of  the 
tongue  with  pyogenic  organisms.  It  may  arise  from  injuries,  or  from 
stomatitis,  particularly  the  mercurial  form  and  those  varieties 
accompanying  low  fevers.  The  tongue  becomes  red  and  painful,  and 
swells  rapidly,  so  that  it  may  protrude  from  the  mouth  and  interfere 
with  speaking,  swallowing,  and  breathing.  Ulceration,  abscess,  or 
even  gangrene  may  follow.  There  is  drooling  of  saliva  and  constitu- 
tional symptoms  of  sepsis.  The  treatment,  in  the  milder  cases,  is  a 
chlorate  of  potassium  mouth  wash  and  the  sucking  of  particles  of 
ice.  If  the  swelling  increases,  a  free  incision  should  be  made  into  the 
tongue  on  each  side  of  the  median  line.  In  the  presence  of  threaten- 
ing asphyxia  tracheotomy  will  be  required. 

Abscess  of  the  tongue  may  be  of  an  acute  nature,  but  is  often 
chronic,  and  encapsulated  by  dense  inflammatory  tissue,  which 
often  leads  to  the  diagnosis  of  a  neoplasm.  The  treatment  is  incision 
and  disinfection  with  antiseptic  mouth  washes. 

Acute  superficial  glossitis  is  but  a  part  of  a  general  stomatitis  and 
need  not  be  described  as  a  separate  affection,  although  a  special 
form,  involving  one-half  of  the  tongue  (hemiglossitis),  usually  with 
herpes,  and  probably  of  nervous  origin,  occurs. 

Chronic  superficial  glossitis,  or  leukoplakia  (psoriasis  or  ichthy- 
osis  of  the  tongue),   is  commonly  attributed  to  syphilis,  smoking, 


644  MANUAL    OF    SURGERY 

whiskey  drinking,  chronic  dyspepsia,  or  ragged  teeth.  Thin  bluish- 
white  or  yellowish  patches  form  on  the  tongue  (Fig.  358)  and  perhaps 
on  the  Hps  and  cheeks.  The  disease  is  very  chronic  and  is  often 
followed  by  epithelioma.  In  some  instances  the  patches  are  shed 
and  the  tongue  becomes  red  and  glazed  or  cracked  and  fissured. 
The  discomfort  is  usually  slight,  although  in  severe  cases  there  may 
be  marked  tenderness  and  interference  with  speaking  and  eating. 
The  treatment  is  removal  of  all  sources  of  irritation,  such  as  tobacco, 
alcohol,  and  highly  seasoned  food.  The  teeth  should  be  put  in 
order  and  an  alkaline  mouth  wash  used,  such  as  sodium  bicarbonate 
20  grains  to  the  ounce.     AppKcations  of  tincture  of  benzoin  or  myrrh 


Pig.  358. — Leukoplakia.     The  patch  is  raised,  nodular,  and  whitish,     (Butlin.) 

are  useful,  the  benzoin  or  m}Trh  being  precipitated  as  a  varnish. 
Caustics  should  be  avoided.  If  the  disease  is  not  too  extensive 
excision  of  the  patches  is  the  best  treatment. 

H3^erkeratosis  Linguae  (black  tongue)  is  a  rare  condition  in  ^^■hich 
the  mucous  membrane  just  in  front  of  the  circumvallate  papillae 
becomes  dark  or  black  and  covered  with  long,  waving  papillae  re- 
sembKng  hairs.     The  color  is  supposed  to  be  due  to  bacteria. 

Ulceration  of  the  tongue  due  to  trauma,  ragged  teeth,  dyspepsia 
and  stomatitis  readily  heals  on  removal  of  the  cause.  Herpetic 
ulcers  follow  herpes,  and  are  treated  w^th  applications  of  silver 
nitrate  and  an  antiseptic  wash.     Lupus  and  actinomycosis  are  rare. 


UPPER   DIGESTIVE    APPARATUS  645 

Tuhcrculous  ulcers  may  be  primary,  but  are  usually  secondary  to 
disease  of  the  lungs.  As  a  rule  they  are  on  or  near  the  tip  of  the 
tongue  and  have  sharply  defined  irregular  edges,  pale  flabby  granu- 
lations, and  but  little  induration.  They  are  very  painful  and  may 
reach  a  large  size.  The  treatment  is  excision.  The  most  important 
ulcers  of  the  tongue  are  the  syphilitic  and  the  malignant. 

Syphilis  of  the  tongue  is  seen  as  the  chancre,  mucous  patches, 
condylomata,  ulcers,  glossitis,  and  gumma.  Syphilitic  glossitis 
may  be  of  the  chronic  superficial  variety,  or  the  whole  tongue  may  be 
enlarged,  hardened,  and  marked  by  deep  fissures,  which  result  from 
contraction  of  newly  formed  fibrous  tissue.     Gumma  is  usually  on  the 


y 


Pig.  359. — Epithelioma  of  the  tongue.  The  edges  of  the  ulcer  are  thick  and  everted; 
the  rest  of  the  tongue  is  covered  with  a  thick  green-black  fur  due  to  the  foul  condition  of 
the  mouth  and  the  immobility  of  the  tongue  (Butlin). 

dorsum  near  the  median  line  and  may  be  multiple.  It  is  preceded 
by  a  chancre,  associated  with  lesions  in  other  parts  of  the  body,  is  apt 
to  occur  in  the  earlier  half  of  life,  is  more  common  in  the  female 
and  begins  as  a  submucous  infiltration  which  finally  ulcerates. 
The  ulcer  is  round  or  oval,  punched  out,  deep,  nearly  painless, 
and  covered  by  the  characteristic  gummy  material.  Induration  is 
slight,  the  submaxillary  glands  frequently  unaffected,  the  tongue 
mobile,  articulation  and  deglutition  but  little  disturbed,  and  cachexia 
absent.  In  doubtful  cases  a  piece  may  be  excised  for  microscopic 
examination,  a  Wassermann  test  made,  and  the  effect  of  iodid  of 
potassium  internally  tried. 


646  MANUAL    OF    SURGERY 

Cancer  of  the  tongue  is  always  a  squamous  epithelioma.  It  is 
most  frequent  in  men  after  forty,  and  is  often  preceded  by  some  form 
of  irritation,  such  as  that  produced  by  irregular  teeth,  smoking  or 
chewing  tobacco,  leukoplakia,  or  gumma.  It  may  attack  any  portion 
of  the  tongue,  but  is  most  frequent  in  the  anterior  half  of  the  margin 
of  the  organ.  It  may  begin  as  a  crack  or  nodule,  but  usually  starts 
as  an  ulcer,  which  spreads  rapidly  to  the  floor  of  the  mouth  and  the 
jaw,  so  that  the  tongue  becomes  fixed,  and  articulation  and  degluti- 
tion dil^cult.  The  ulcer  is  surrounded  by  an  indurated  area  and  is 
often  exceedingly  painful.  The  edges  are  thick  and  everted,  the 
base  foul  and  sloughing,  and  the  discharge  fetid  (Fig.  359).  There  is 
incontinence  of  saliva,  and  bleeding  occurs  on  sHght  provocation. 
The  submaxillary  glands  are  involved  early  and  cachexia  promptly 
supervenes.  The  condition  is  easily  recognized  in  the  later  stages, 
but  at  the  onset  the  diagnosis  may  be  impossible  without  a  micro- 
scopic examination,  which  should  be  promptly  made  in  all  doubtful 
cases. 

The  treatment  is  excision  of  the  growth  with  the  lymphatic  area 
into  w^hich  it  drains.  Without  operation  death  generally  occurs  in 
from  one  year  to  eighteen  months;  with  early  and  thorough  operation 
20  per  cent.,  according  to  Buthn,  remain  free  from  recurrence  after 
three  years.  Very  small  growths  may  be  removed  by  a  V-shaped  or 
ellipitcal  incision  which  is  subsequently  sutured,  but  in  most  in- 
stances it  will  be  necessary  to  remove  half  or  all  of  the  tongue.  The 
teeth  should  first  be  cleansed  by  a  dentist,  and  the  mouth  rinsed 
every  three  or  four  hours  with  an  antiseptic  mouth  wash.  The 
mortality  of  excision  is  about  5  per  cent.,  most  deaths  occurring  from 
septic  pneumonia,  the  result  of  inhalation  of  blood  and  wound 
discharges,  hence  the  patient  should  be  put  in  the  Trendelenburg  or 
the  Rose  posture  during  operation.  Some  surgeons  perform  a 
preliminary  tracheotomy,  and  pack  the  pharynx  with  gauze  at  the 
time  of  operation,  but  this  is  unnecessary  if  one  employs  intratracheal 
insufflation  anesthesia. 

Whitehead's  operation  consists  in  removal  of  the  tongue  through 
the  mouth.  The  jaws  are  separated  by  a  gag  and  the  tongue  drawn 
forward  by  a  ligature  passed  through  its  tip.  The  tongue  is  then 
separated,  with  the  sublingual  gland,  from  the  floor  of  the  mouth 
by  scissors,  the  Ungual  arteries  being  seized  with  forceps  before  they 
are  cut.  A  ligature  is  now  passed  through  the  glosso-epiglottic 
fold,  and  the  tongue  severed  in  front  of  the  hgature.  The  ligature 
is  left  in  place  twenty-four  hours,  in  order  to  pull  the  epiglottis 
forward  if  there  be  bleeding  or  trouble  with  breathing.     The  wound 


UPPER    DIGESTIVE   APPARATUS  647 

is  painted  with  Whitehead's  varnish  (  Friar's  balsam  in  which  the  alco- 
hol is  replaced  by  a  saturated  solution  of  iodoform  in  ether),  or  com- 
pound tincture  of  Benzoin.  The  cervical  lymph  glands  are  then 
removed.  Most  surgeons,  however,  prefer  to  excise  the  glands  first, 
as  this  permits  ligation  of  the  lingual  artery  and  postpones  invasion 
of  the  mouth  until  the  clean  part  of  the  operation  is  finished.  The 
patient  sits  up  as  soon  as  the  effects  of  the  anesthetic  have  passed,  and 
is  fed  by  mouth  from  the  beginning,  or,  if  need  be,  by  the  nasal  tube 
or  by  the  rectum.  Removal  of  half  of  the  tongue  is  accomplished 
in  the  same  manner,  except  that  the  organ  is  split  in  the  middle  line. 

Kocker's  operation  is  indicated  in  cases  in  which  the  floor  of  the 
mouth  or  the  jaw  is  involved.  An  incision  is  made  from  below  the 
symphysis  to  above  the  hyoid  bone,  then  to  the  anterior  margin 
of  the  sterno-mastoid,  and  lastly  upwards  to  the  mastoid  process. 
The  flap  is  turned  upwards  and  all  the  lymphatic  glands  in  this  region, 
with  the  submaxillary  salivary  gland,  excised,  the  lingual  and  facial 
arteries,  or,  perhaps  better,  the  external  carotid  being  ligated.  The 
hyoglossus  and  mylohyoid  muscles  are  divided  and  the  mouth  entered. 
The  tongue  is  drawn  through  this  opening,  and  divided  close  to  the 
epiglottis  and  hyoid  bone.  The  same  precautions  as  in  the  White- 
head operation  should  be  taken  in  regard  to  the  stump  of  the  tongue. 
The  incision  in  the  neck  is  partly  closed,  and  the  cavity  packed  with 
gauze.  The  patient  is  fed  through  the  nose  or  per  rectum,  until  the 
power  of  deglutition  returns.  The  mouth  and  the  wound  should  be 
irrigated  frequently  with  boric  acid  or  salt  solution. 

Sedillot's  operation  is  performed  by  dividing  the  lower  lip  in  the 
median  line  and  extending  the  incision  to  the  hyoid  bone.  The  lower 
jaw  is  sawed  through  in  the  middle  line  and  the  two  halves  retracted. 
The  tongue  is  then  removed  with  scissors  or,  as  performed  by  Kocher, 
who  has  recently  adopted  this  operation,  with  the  cautery.  A  small 
amount  of  xeroform  is  rubbed  into  the  wound,  the  divided  jaw  wired, 
and  the  wound  in  the  soft  parts  closed  except  below,  where  a  gauze 
drain  linds  exit. 

Sarcoma,  benign  tumors,  and  cysts  occur  in  the  tongue  but  are 
very  rare. 

THE  MOUTH,  JAWS,  AND  PHARYNX 

Stomatitis,  or  inflammation  of  the  mouth,  may  be  caused  by 
mechanical  or  chemical  irritants,  dyspepsia,  fevers,  and  by  a  specific 
fungus,  oidium  albicans  {thrush) .  The  simple  catarrhal  form  presents 
the  ordinary  phenomena  of  inflammation,  and  quickly  subsides 
when   the  cause  is  removed.     Aphthous  stomatitis  occurs  as  small 


648  MANUAL    OF    SURGERY 

whitish  vesicles,  which  form  ulcers  surrounded  by  a  red  areola.  It  is 
seen  in  children  with  digestive  disturbances.  Ulcerative  stomatitis 
occurs  in  debilitated  children,  and  in  adults  with  diabetes  or  Bright's 
disease.  Attention  has  already  been  called  to  gangrenous,  syphilitic, 
and  mercurial  stomatitis.  Certain  forms  of  skin  eruptions  also  may 
attack  the  mucous  membrane  of  the  mouth.  The  treatment  of 
stomatitis  is  removal  of  the  cause,  attention  to  the  general  health, 
proper  feeding,  and  the  use  of  a  mouth  wash  containing  chlorate  of 
potash.     Ulcers  may  be  touched  with  silver  nitrate. 

Pyorrhea  alveolaris  {Riggs^  disease)  is  characterized  by  a  collection 
of  tartar  and  chronic  suppuration  beneath  the  margins  of  the  gums, 
which  atrophy  and  recede  from  the  teeth,  leaving  them  loose.  It 
may  be  responsible  for  fetid  breath,  dyspepsia,  anemia,  cervical 
adenitis,  and  various  forms  of  so-called  cryptogenic  sepsis.  The 
treatment,  which  can  be  carried  out  only  by  a  dentist,  consists  in 
removal  of  the  tartar  and  frequent  antiseptic  treatment. 

Alveolar  abscess  is  due  to  irritation  from  a  decayed  tooth.  When 
superficial  it  is  known  as  gum  boil.  Occasionally  the  pus  passes 
beneath  the  periosteum  and  causes  necrosis  of  the  jaw.  In  the 
upper  jaw  the  antrum  may  be  opened,  in  the  lower  jaw  the  pus  may 
point  in  the  neck.  The  treatment  is  drainage  of  the  abscess  cavity, 
and  generally  extraction  of  the  tooth.  If,  however,  the  tooth  is 
but  slightly  diseased,  it  may  be  saved  by  appropriate  dental 
treatment. 

Necrosis  of  the  jaw  may  be  caused  by  injury,  caries  of  the  teeth, 
phosphorus,  arsenic,  mercury,  syphilis,  tuberculosis,  actinomycosis, 
and  the  exanthemata.  The  symptoms  in  the  beginning  are  pain, 
swelling  of  the  face  and  gums,  fever,  and  the  formation  of  an  abscess, 
which  may  point  in  the  mouth,  or  externally  on  the  face  or  neck. 
The  discharge  is  offensive,  and  dead  bone  can  be  felt  with  the  probe, 
or  seen  with  the  X-ray.  An  involucrum  may  form  in  the  lower  jaw, 
but  is  uncommon  in  the  upper  jaw.  The  treatment  is  incision  for 
the  purposes  of  drainage,  and  antiseptic  mouth  washes  until  the  se- 
questrum is  loose,  when  it  should  be  removed  through  the  mouth, 
or  if  this  is  not  possible,  by  an  external  incision.  The  defect  may 
be  closed  by  one  of  the  methods  to  be  mentioned  under  excision  of 
the  lower  jaw. 

Cysts  of  the  jaws  generally  arise  in  connection  with  the  teeth,  or 
are  the  result  of  a  cystic  change  in  solid  tumors,  particularly  sarcoma 
and  epithelioma.  Dental  Cysts  occurring  in  connection  with  com- 
pletely developed  teeth  are  of  inflammatory  origin,  the  fluid  collect- 
ing between  the  root  and  the  peridental  membrane.     The  treatment 


UPPER   DIGESTIVE    APPARATUS  649 

is  extraction  of  the  tooth.  Dciiliiicrous  cysls  (folHcular  odontomata, 
chap,  xiii)  are  caused  by  the  non-eruption  of  a  tooth.  The  swelling 
is  at  first  hard,  but  later  egg-shell  crackling  may  be  noted.  Occasion- 
ally suppuration  occurs.  The  permanent  tooth  is  absent,  but 
sometimes  the  milk  tooth  persists,  and  may  be  mistaken  for  a 
permanent  one  unless  an  X-ray  examination  is  made.  The  treatment 
is  excision  of  the  anterior  wall  of  the  cyst,  removal  of  the  unerupted 
tooth,  and  gauze  packing.  Fibrocystic  disease  of  the  lower  jaw 
(epithelial  odontome)  is  a  multilocular  cystic  formation,  which  may 
attain  a  great  size,  and  is  most  frequently  observed  in  the  young. 
It  has  been  mistaken  for  sarcoma.     The  treatment  is  excision. 

Ttunors  of  the  jaws  comprise  the  fibroma,  enchondroma,  osteoma, 
odontoma  (chap,  xiii),  sarcoma,  and  epithelioma.  In  many 
tumors  of  the  jaws,  especially  in  the  young,  one  should  first  make 
sure,  by  X-ray  examination,  puncture,  or  even  incision,  that  the 
growth  is  not  a  benign  cyst,  before  deciding  on  extirpation.     Epulis 


Fig.  360. — Malignant  epulis  (sarcoma).        Fig.  361. — Sarcoma  of  lower  jaw. 

is  a  term  apphed  to  tumors  originating  in  the  alveolar  periosteum. 
A  simple  epulis  is  smooth,  round,  red,  elastic,  and  generally  fibroma- 
tous  in  nature.  It  may  ulcerate  or  become  ossified.  A  malignant 
epulis  (Fig.  360)  is  a  myeloid  sarcoma,  which  is  soft  and  purplish, 
grows  rapidly,  bleeds  easily,  and  may  ulcerate.  The  treatment  of 
epulis  is  excision  of  the  alveolar  process  as  far  as  one  tooth  on  each 
side  of  the  growth.  Fibroma  and  enchondroma  are  more  apt  to 
appear  early  in  life,  grow  slowly,  and  sometimes  recur  after  removal, 
possibly  because  of  the  presence  of  some  sarcomatous  tissue.  The 
treatment  is  removal,  with  that  portion  of  the  jaw  to  which  they  are 
attached.  Osteoma  occurs  later  in  life  and  sometimes  follows  injury 
or  inflammation  of  the  bone.  It  should  be  removed.  Sarcoma  (Fig. 
361)  may  occur  at  any  period  of  life,  and  is'the  most  frequent  form 
of  tumor  attacking  the  jaws.  It  may  be  of  any  variety.  The  soft 
forms  (containing  round  cells)  grow  rapidly  and  invade  or  displace 
the  surrounding  structures;  thus  in  the  upper  jaw  there  may  be  a 


650  MANUAL    OF    SURGERY 

projection  beneath  the  cheek,  depression  of  the  palate,  obstruction 
of  the  nose  with  the  discharge  of  blood  or  pus,  epiphora,  exophthal- 
mos, and  severe  pain  owing  to  implication  of  the  nerves.  Epithelioma 
occurs  in  the  later  period  of  life,  and  begins  in  the  mucous  membrane 
of  the  mouth,  nose  or  antrum.  The  symptoms  are  much  like  those 
of  sarcoma,  but  ulceration  is  more  frequent  and  the  lymphatic 
glands  are  quickly  involved.  The  treatment  of  sarcoma  and  epitheli- 
oma is  partial  or  complete  excision  of  the  jaw,  according  to  the  extent 
of  the  growth. 

Excision  of  the  upper  jaw  may  be  required  for  the  removal  of 
growths  within  or  behind  the  bone.     Inspiration  of  blood   is  pre- 
vented by  placing  the  patient  in  the  Rose  position,  and  employing 
intratracheal  insufflation  anesthesia.     Bleeding  may  be  lessened  by 
ligation  of  the  external  carotid,  or  by  temporary  occlusion  of  the 
common  carotid  by  means  of  Crile's  clamp.     An  incision  is  made  from 
the  malar  bone  along  the  margin  of  the  orbit  to  half  an  inch  below  the 
inner  canthus,  thence  downwards  along  the  side  of  the  nose  and 
around  the  ala  to  the  median  line,  at  which  point  the  upper  lip  is 
divided.     The  flap  is  reflected,  and  the  malar  bone  and  nasal  process 
divided  with  a  saw,  after  the  infraorbital  periosteum  has  been  separated 
and  carefully  retracted  upwards.     The  central  incisor  tooth  of  the 
aft'ected  side  is  extracted,  and  the  mucous  membrane  of  the  roof  of 
the  mouth  divided  in  the  median  line  as  far  as  the  soft  palate,  and 
then  transversely  between  the  hard  and  soft  palates.     A  narrow  saw 
is  now  passed  into  the  nose,  and  the  alveolus  and  hard  palate  divided 
from  before  backwards.     The  bone  is  seized  with  lion-jawed  forceps 
and  twisted  from  its  bed  by  fracturing  the  pterygoid  processes  and 
the  lateral  mass  of  the  ethmoid.     The  bleeding  vessels  are  caught  and 
tied,  and  the  cavity  filled  with  gauze  packing.     The  entire  skin 
wound  is  sutured,  the  gauze  being  subsequently  removed  and  irriga- 
tions practised  through  the  mouth.     The  patient  is  at  first  fed  by 
the  rectum  or  by  an  esophageal  tube.     The  resulting  deformity  may 
be  corrected  by  means  of  an  obturator  and  cheek-plate. 

Temporary  resection  of  the  upper  jaws  (Kocher)  is  useful  in 
exposing  certain  nasopharyngeal  growths.  The  upper  lip  is  split 
into  one  nostril  and  both  flaps  separated  from  the  bone.  The  alve- 
olar process  and  palate  are  then  split  in  the  middle  line  with  a 
chisel,  and  both  upper  jaws  divided  horizontally  on  a  level  with  the 
lower  portion  of  the  nasal  processes,  thus  permitting  retraction.  At 
the  completion  of  the  operation  the  bones  are  wired  in  place. 

Excision  of  the  lower  jaw  is  performed  for  tumors  and  necrosis. 
Small  portions  of  the  jaw  can  often  be  resected  through  the  mouth. 


UPPER   DIGESTIVE   APPARATUS  65 1 

If  the  symphysis  is  removed,  the  muscles  attached  to  the  genial 
tubercles  are  divided,  and  a  ligature  must  be  passed  through  the 
tongue  to  prevent  its  falling  backwards.  The  periosteum  should 
be  preserved  whenever  possible.  Resection  of  the  entire  lower  jaw 
is  performed  by  dividing  the  bone  in  the  median  line  and  deaUng 
with  each  half  separately.  The  incision  for  removal  of  one-half  the 
lower  jaw  is  made  from  below  the  free  margin  of  the  lower  lip  down- 
wards in  the  median  line,  then  along  the  under  surface  of  the  jaw  and 
upwards  along  the  posterior  border  of  the  ramus  to  below  the  Hne 
for  the  facial  nerve.  The  facial  vessels  are  tied,  the  soft  parts 
separated  from  the  bone,  the  central  incisor  tooth  extracted,  and  the 
jaw  sawed  through  the  empty  socket,  thus  avoiding  the  genial  tuber- 
cles. By  pulling  the  bone  outwards  the  internal  soft  parts  can  be 
separated  and  the  inferior  dental  artery  tied.  The  jaw  is  now  de- 
pressed and  the  coronoid  process  and  the  condyle  separated  by  cut- 
ting close  to  the  bone,  recalling  that  the  internal  maxillary  lies  very 
near  the  condyle.  The  buccal  mucous  membrane  is  sutured  to  that 
of  the  floor  of  the  mouth  and  the  external  wound  closed.  In  order  to 
correct  the  resulting  deformity,  which  is  increased  by  the  passage  of 
the  remaining  half  of  the  bone  towards  the  affected  side,  splints  of 
aluminium,  hard  rubber,  and  even  bone  grafts  (rib,  crests  of  tibia) 
have  been  inserted.  Morestin  implants  a  piece  of  bone  or  cartilage 
beneath  the  skin  of  the  arm,  and,  after  vascular  connections  have 
been  obtained,  transplants  it  by  the  Italian  method  to  the  jaw. 
Operations  of  this  character  are  less  apt  to  succeed  here  than  else- 
where, because  complete  asepsis  cannot  be  secured. 

Closure  of  the  jaws  may  be  caused  by  ankylosis  of  the  temporo- 
maxillary  joint  the  result  of  injury  or  inflammation ;  cica^naa/  contrac- 
tion of  the  soft  parts  following  noma,  burns,  etc.;  trismus  (spasm  of 
the  muscles),  the  result  of  tetanus,  hysteria,  or  local  causes,  such  as 
an  unerupted  wisdom  tooth  or  caries  of  the  teeth;  and  hy  inflammatory 
or  neoplastic  lesions  which  mechanically  interfere  with  opening  of 
the  mouth,  e.g.,  mumps  and  mahgnant  growths.     (Fig.  109.) 

The  treatment  of  temporary  closure  of  the  jaws  depends  upon  the 
cause.  Permanent  closure  due  to  bony  or  fibrous  ankylosis  of  the 
temporomaxillary  joint  is  best  treated  by  resection  of  the  condyle, 
with  the  interposition  of  a  flap  from  the  temporal  or  masseter  muscle. 
The  dangers  are  injury  to  the  facial  nerve  and  internal  maxillary 
artery.  When  the  jaws  are  bound  together  by  extra-articular  cicatri- 
ces, a  wedge-shaped  section  of  bone,  with  the  apex  towards  the  alveo- 
lar process,  should  be  excised  in  front  of  the  cicatrix,  and  a  false 
joint  established  by  the  interposition  of  muscle  or  fascia. 


6s2 


MANUAL    OF    SURGERY 


Cleft  palate  is  a  congenital  deformity  caused  by  failure  of  the 
palatine  processes  to  unite.  Beginning  posteriorly  the  cleft  may 
extend  a  variable  distance,  the  mildest  form  presenting  itself  as  a 
bifid  uvula,  and  the  severest  form  as  a  wide  cleft  involving  the  whole 

palate  and  dividing  anteriorly  to  embrace 
the  OS  incisivum  and  the  middle  segment 
of  the  upper  hp.  The  septum  of  the  nose 
may  be  free  or  it  may  have  united  with  one 
of  the  palatine  processes,  usually  the  right. 
Cleft  palate  interferes  with  sucking  and  in 
later  life  with  swallowing  and  articulation. 
Operation  may  be  performed  in  early 
Pig.  362.— z  and  Q     Line  infancy  if  the  patient  is  in  good  condition. 

of  separation   of   attachments  '■  °  ^ 

of  velum  to  hard  palate.  X,  Some  surgcons,  however,  prefer  to  wait  until 
p'i,?„k?;^Tco"„ti;tis"rh  the  second  or  third  year,  the  patient  being 
the  velum)  is  separated  from  fed  in  the  meantime  with  a  spoon  or  tube 

the  bone.      (Binnie.)  •   i      1      i 

With  the  head  thrown  well  back.  All  agree 
that  operation  should  be  done  before  habits  of  faulty  articulation  have 
developed.  If  there  is  an  associated  hare-lip  the  cleft  palate  should 
be  closed  first.  At  the  time  of  operation,  preferably  in  the  spring 
or  summer,  the  child  should  be  free  of  local  and  general  disease. 
The  nose  and  mouth  should  be  cleansed  for  a  few  days  before  opera- 
tion with  a  solution  of  boric  acid.     The  child  is  anesthetized  with 


Fig.  363. — (Binnie.) 


Fig.  364. — (Binnie.) 


Fig.  365. — (Binnie.) 


ether  placed  in  the  Rose  or  the  Trendelenburg  posture,  and  a  mouth 
gag  introduced. 

Staphylorrhaphy,  or  suture  of  the  soft  palate  alone,  is  performed 
by  paring  the  edges  of  the  cleft,  which  is  then  united  with  silk  sutures. 
If  this  cannot  be  done  without  too  great  tension,  relaxation  may  be 
secured  by  dividing  the  tissues  which  attach  the  soft  to  the  hard 
palate,  excepting  the  oral  mucous  membrane,  and  by  undermining 
the  muco-periosteum  of  the  hard  palate  (Fig.  362).  Division  of  the 
muscles  of  the  soft  palate  is  not  advisable. 


UPPER   DIGESTIVE    APPARATUS 


653 


Uranoplasty,  or  suture  of  the  hard  palate,  may  be  performed  as 
follows:  The  edges  of  the  cleft. are  pared  with  a  tenotome  (Fig.  363), 
and  the  muco-periosteum  separated  from  the  hard  palate  with  a 
periosteal  elevator  (Fig.  364)  as  far  as  the  alveolar  process,  being 
careful  to  avoid  injury  to  the  vessels  passing  through  the  anterior 
and  posterior  palatine  canals.  The  soft  palate  is  separated  from 
the  hard  palate  as  in  staphylorrhaphy.     The  edges  are  now  united 


a 


Fig.  366. — (Binnie.) 


Fig.  367. — (Binnie.) 


with  interrupted  sutures  of  silkworm  gut.  If  the  edges  do  not  come 
together  without  tension,  an  incision  on  one  or  both  sides  is  made 
through  the  muco-periosteum  near  the  alveolus,  from  the  lateral 
incisor  tooth  to  the  posterior  edge  of  the  hard  palate.  Tension  may 
further  be  reheved  by  dividing  the  hamular  process  with  a  chisel. 
Some  surgeons  chisel  also  through  the  hard  palate  on  each  side,  pry 
the  bone    inwards,  and  pack  the  resulting  gap  with  gauze.     Al- 


Fig.  368. — (Binnie.) 

though  special  needles  are  recommended  for  this  operation,  a  sharply 
curved  needle  and  a  needle  holder  are  sufficient  for  every  purpose. 
The  sutures  remain  in  place  ten  days,  during  which  time  liquid  or 
soft  food  only  should  be  given.  Antiseptic  sprays  may  be  employed. 
Brophy's  operation  is  applicable  during  the  first  six  months  of  fife 
while  the  bones  are  still  soft.  By  means  of  a  special  needle,  a  loop 
of  silk,  then  a  piece  of  silver  wire,  is  passed  through  both  upper  jaws 
above  the  palate  just  behind  the  malar  processes.     A  second  piece  of 


654  MANUAL    OF    SURGERY 

wire  is  passed  through  the  anterior  portion  of  the  upper  jaw,  and  the 
ends  of  these  wires  are  twisted  together  over  a  lead  plate  while  the 
cleft  is  closed  by  pressing  the  two  superior  maxillary  bones  together, 
the  edges  of  the  cleft  having  previously  been  pared.  Fig.  365  illus- 
trates a  plan  in  which  the  lower  part  of  the  septum  is  used  to  close  a 
unilteral  cleft  palate.  The  septum  is  severed  at  X,  and  the  lower  por- 
tion sutured  to  the  pared  edge  of  the  free  palatine  process.  Figs. 
366,  367,  and  368  illustrate  other  operations  for  cleft  palate.  In 
about  one-half  of  the  cases  a  second  operation  is  required.  A  cleft 
may  be  closed  also  by  means  of  an  obturator,  fitted  by  a  dentist. 

Perforations  of  the  palate  are  usually  caused  by  syphilis,  occasion- 
ally by  traumatism  or  lupus.  If  the  local  disease  is  cured,  the 
perforation  may  be  closed  by  a  plastic  operation,  although  in  most 
syphilitic  cases  better  results  are  obtained  by  the  use  of  obturators. 

Elongation  of  the  uvula  when  troublesome  may  be  remedied  by 
removing  the  lower  portion  with  scissors. 

Suppurative  tonsilitis,  or  quinsy,  may  follow  exposure  to  cold  or 
polluted  air.  Certain  individuals  are  predisposed  to  this  affection 
particularly  during  adolescence.  The  tonsils,  the  fauces,  and  the 
soft  palate  are  swollen  and  edematous,  causing  interference  with 
breathing,  swallowing,  and  speaking.  There  are  pain  in  the  throat, 
enlargement  of  the  cervical  glands,  and  marked  constitutional 
symptoms.  Both  tonsils  may  be  involved,  and  the  patient  may  be 
unable  to  open  the  mouth.  The  treatment  in  the  initial  stage  is  an 
ice  bag  externally,  scarification  of  the  tonsil,  a  chlorate  of  potash 
gargle,  and  symptomatic  internal  treatment.  When  pus  forms,  the 
abscess  may  be  opened  with  a  sharp  pointed  tenotome,  the  incision 
being  parallel  with  the  anterior  pillar  of  the  fauces  and  directed 
towards  the  middle  line. 

Hypertrophy  of  the  tonsils  is  most  frequent  in  children  and  indeed 
may  be  congenital.  It  may  follow  repeated  acute  attacks  of  inflam- 
mation and  is  often  a  manifestation  of  a  tuberculous  diathesis.  It  is 
usually  associated  with  adenoids  and  hence  presents  the  same 
symptoms  as  the  latter.  Caseous  and  calcareous  concretions  may 
form  in  the  crypts  of  the  tonsils,  and  cysts  occasionally  develop  from 
blocking  of  the  orifices  of  the  foUicles.  The  treatment  is  attention 
to  the  general  health  and  removal  of  a  portion  (tonsillotomy)  or  of 
the  whole  gland  (enucleation).  The  galvanocautery  is  often  re- 
commended in  adults  because  of  the  greater  risk  of  severe  hemor- 
rhage at  this  time  of  life.  Tonsillotomy  may  be  performed  with  a 
bistoury,  the  guillotine  or  with  a  wire  sware.  In  the  first  instance 
the   tonsil  is  drawn  inwards  with  a  tenaculum,  and  removed  by 


UPPER   DIGESTIVE   APPARATUS 


655 


cutting  from  below  upward  with  u  blunt  pointed  bistoury,  the 
blade  of  which  is  wrapped  to  within  an  inch  of  the  point  with  adhesive 
plaster.  The  guillotine,  or  tonsillotome  (Fig.  369),  facilitates  the 
operation.  The  ring  of  the  instrument  is  passed  over  the  tonsil, 
which  is  pressed  inwards  with  the  fingers  behind  the  angle  of  the  jaw, 
then  by  approximating  the  fingers  and  thumb  the  tonsil  harpooned, 
and  amputated  with  the  ring-shaped  knife.  Before  either  operation 
adhesions  to  the  arches  of  the  palate  should  be  separated.  Enuclea- 
tion is  now  preferred  to  tonsillotomy,  as  after  the  latter  the  portion 
of  gland  left  behind  may  lead  to  recurrence.  With  a  linger  or  blunt 
dissector  the  tonsil  is  shelled  from  its  bed,  and  then  expressed  from 
between  the  f  aucial  pillars  with  an  ecraseur,  blunt  tonsillotome  or  wire 
sware.  Hemorrhage  after  these  operations  usually  ceases  promptly, 
but  occasionally  persists,  the  blood  coming  from  the  tonsillar  branch 
of  the  facial.     If  it  cannot  be  controlled  by  adrenalin  and  pressure. 


Fig.  369. — Tonsillotome. 


(Zuckerkandl.) 


the  wound  should  be  united  by  deep  sutures;  rarely  will  it  be  neces- 
sary to  tie  the  external  carotid. 

Tumors  of  the  tonsils  are  generally  mahgnant,  lympho-sarcoma 
being  the  most  frequent  variety.  Epithelioma  is  usually  secondary. 
Both  these  growths  cause  enlargement  of  the  lymph  glands,  interfere 
with  deglutition  and  respiration,  and  undergo  ulceration,  which 
often  causes  a  serious  or  fatal  hemorrhage.  The  treatment  is 
extirpation.  A  small  encapsulated  sarcoma  may  be  enucleated 
through  the  mouth,  but  most  mahgnant  growths  will  have  to  be 
dealt  with  from  the  neck.  An  incision  is  made  along  the  anterior 
border  of  the  sternomastoid,  the  lymphatic  glands  removed,  the 
external  carotid  tied,  and  the  growth  excised.  It  may  be  necessary 
to  divide  the  lower  jaw,  or  to  incise  the  cheek  from  the  angle  of  the 
mouth  backwards. 

Retropharyngeal  abscess  may  be  acute  or  chronic,  and  is  most 


656  MANUAL   OF    StfRGERY 

frequent  in  children.  Acute  abscesses  may  be  caused  by  foreign 
bodies,  or  by  infection  of  the  lymph  glands  in  this  region,  which 
drain  the  nose  and  nasopharynx.  The  chronic  form  is  usually  the 
result  of  caries  of  the  spine  or  base  of  the  skull,  and  is  not  associated 
with  the  fever  and  inflammatory  phenomena  characteristic  of  the 
former.  In  either  case  the  posterior  wall  of  the  pharynx  bulges 
forward,  exhibits  fluctuation,  and  may  interfere  with  deglutition  and 
respiration.  If  unopened,  the  abscess  will  break  into  the  pharynx, 
point  externally  in  the  neck,  or  gravitate  into  the  posterior  mediasti- 
num. The  treatment  is  evacuation  through  the  mouth  in  acute  cases, 
and  through  the  neck  in  chronic  cases,  as  in  the  latter  secondary 
infection  should  be  prevented.  When  the  abscess  is  to  be  opened 
through  the  mouth,  the  head  should  hang  over  the  edge  of  the  table 
in  order  to  prevent  the  entrance  of  pus  into  the  air  passages,  and  the 
abscess  opened  with  a  knife,  the  edge  of  which  is  covered  with  adhe- 
sive plaster  to  near  the  point,  or  a  pair  of  sharp  pointed  curved 
hemostats  may  be  thrust  into  the  abscess  and  withdrawn  while 
opened.  Anesthesia  is  dangerous.  When  the  abscess  is  opened 
through  the  neck,  an  incision  is  made  along  the  posterior  border  of 
the  sternomastoid  from  the  apex  of  the  mastoid  downwards,  unless 
the  abscess  points  in  some  other  region.  The  finger  or  a  pair  of 
forceps  is  passed  along  the  anterior  surface  of  the  bodies  of  the 
vertebrae  and  a  drainage  tube  inserted. 

THE  ESOPHAGUS 

The  esophagoscope  is  a  long,  straight,  cylindrical  speculum, 
illuminated  by  an  electric  lamp,  best  placed,  as  in  the  Jackson  instru- 
ment, at  the  distal  end.  For  esophagoscopy  anesthesia  is  not  essent- 
ial, although  the  pharynx  and  the  upper  end  of  the  esophagus  may 
be  cocainized  if  the  operator  so  desires.  The  esophagus  below  its 
pharyngeal  opening  is  insensitive.  Etherization  renders  the  opera- 
tion less  difficult,  hence,  unless  contraindicated,  may  be  selected  by 
the  beginner.  Cocain  is  dangerous  in  children,  and  if  there  is  a 
foreign  body  in  the  esophagus  pressing  on  the  trachea,  ether  should 
not  be  given  except  by  intratracheal  insulSation.  The  patient 
lies  on  the  back  with  the  head  extending  over  the  end  of  the  table.  An 
assistant  places  his  right  forearm  beneath  the  neck  of  the  patient 
and  holds  the  forehead  with  his  right  hand.  "The  esophagoscope 
is  inserted  at  the  right  of  the  patients'  tongue,  and  the  pyriform 
sinus  sought  immediately  to  the  right  of  the  right  arytenoid.  Once 
the  tube  is  in  the  sinus,  very  gentle  pressure  is  used,  and  the  lumen 


UPPER    DIGESTIVE    APPARATUS  657 

of  the  mouth  of  the  esophagus  is  watched  for  and  followed  at  the 
moment  of  inspiration.  Absolutely  no  force  should  be  us^d,  and  no 
attempt  to  advance  the  tube  should  be  made  except  when  the  patient 
takes  a  deep  breath.  It  is  the  spasm  of  the  inferior  constrictor 
at  the  cricoid  level  that  gives  the  trouble.  Once  this  is  passed,  the 
lumen  of  the  cervical  esophagus  is  easily  explored,  and  the 
thoracic  esophagus  opens  widely  at  each  recurrence  of  the 
inspiratory  negative  intrathoracic  pressure.  Passing  the  hiatus 
esophageus  requires  a  moment  for  relaxation  of  the  spasm,  and  the 
tube  must  be  directed  slightly  upward  (patient  recumbent)  and  to 
the  left"  (Jackson).  As  wdth  the  bronchoscope  suitably  constructed 
forceps  are  provided  for  the  removal  of  foreign  bodies  and  bits  of 
tissue.  Instruments  for  applying  medicaments  to  the  wall  of  the 
esophagus,  for  cutting  or  divulsing  strictures,  etc.,  also  are  employed. 

Congenital  malformations  of  the  esophagus  include  fistulas 
diverticula,  and  cystic  growths,  such  as  have  already  been  mentioned 
in  speaking  of  the  branchial  clefts.  Stenosis,  atresia  and  absence  of 
the  esophagus  also  have  been  noted,  as  w^ell  as  double  esophagus  and 
opening  of  the  esophagus  into  the  trachea. 

Acquired  diverticula  occur  in  three  forms.  Pulsion  or  pressure 
diverticula  most  frequently  originate  during  the  latter  half  of  life. 
The  favorite  site  is  in  the  posterior  wall  at  the  junction  of  the  pharynx 
and  esophagus,  at  which  point  there  are  few  muscular  fibres.  Further, 
there  exists  at  the  beginning  of  the  esophagus  a  normal  constriction 
w^hich  favors  increased  pressure  on  this  weak  point  during  degluti- 
tion. When  consisting  of  mucous  membrane  alone,  a  diverticulum 
is  sometimes  called  a  pharyngocele.  A  sacculation  may  also  be  formed 
from  the  pressure  of  food  above  a  stricture.  Traction  diverticula 
are  due  to  the  contraction  of  scar  tissue,  such  as  may  follow  inflamma- 
tion of  the  bronchial  glands,  hence  they  are  most  frequent  on  the 
anterior  wall  near  the  bifuraction  of  the  trachea.  They  are  usually 
small,  seldom  cause  trouble,  and  are  recognized  at  postmortem  only. 
Pseudodivcrticula  are  formed  by  the  cavity  of  an  abscess  or  cyst  w^hich 
has  emptied  into  the  esophagus. 

The  symptoms  of  pressure  diverticula  are  dysphagia,  a  swelling  of 
the  neck  after  taking  food,  rising  and  falling  with  deglutition,  w^hen  it 
contains  fluid  and  air  a  succussion  sound  may  be  obtained  and  the 
patient  may  notice  a  gurgling  in  the  neck  and  regurgitation  after 
taking  more  food,  owing  to  the  pressure  of  the  distended  sac  on  the 
esophagus,  or  when  the  sac  is  pressed  upon  with  the  fingers.  Cough 
and  dyspnea  may  arise  from  pressure  on  the  trachea  or  nerve  irrita- 
tion.    A  bougie  may  enter  the  sac  at  one  time  and  pass  along  the 

42 


658  MANUAL   OF    SURGERY 

esophagus  at  another.  Plummer  passes  a  bougie,  threaded  on  silk' 
as  described  under  stricture  of  the  esophagus.  If  a  stricture  is 
encountered  the  level  of  the  tip  of  the  bougie  is  not  affected  by 
tightening  the  thread,  but  if  there  is  a  diverticulum,  the  tip  ascends 
to  the  opening  into  the  esophagus,  then  descends  in  the  esophagus. 
After  a  bismuth  meal  the  sac  may  be  outlined  with  the  X-rays. 
Examination  with  the  esophagoscope  may  reveal  the  opening  in  the 
sac.  One  half  of  those  untreated  die  of  inanition,  inspiration  pneu- 
monia, and  perforation  of  the  diverticulum.  The  treatment  is  inci- 
sion along  the  anterior  edge  of  the  left  sternomastoid  (the  esophagus 
inclines  towards  the  left),  retraction  of  the  muscle  and  the  carotid 
vessels  to  the  left  and  the  trachea  to  the  right,  isolation  and  ampu- 
tation of  the  diverticulum  (which  may  be  identified  with  a  bougie), 
suture  of  the  opening  in  the  esophagus,  and  gauze  drainage. 

Idiopathic  dilatation  of  the  esophagus  (car(ifo5/>a5w)  is  character- 
ized by  atony  and  dilatation  of  the  gullet  with  spasm  of  the  cardia; 
which  of  these  is  the  primary  lesion  is  a  matter  of  dispute.  It  may 
be  associated  with  esophagitis  or  disease  of  the  stomach  or  liver,  but 
in  many  instances  no  cause  for  the  spasm  can  be  found,  beyond  the 
fact  that  the  patient  is  nervous.  The  symptoms  are  first  those  of 
spasmodic  stricture,  and,  as  the  spasm  becomes  continuous,  those  of 
organic  stricture  (vide  infra).  The  X-ray  and  the  esophagoscope 
are  important  aids  in  making  a  diagnosis.  If  due  to  functional 
disease  of  the  nervous  system  treatment  with  atropin  is  useful. 
Bromids,  and  valerian  may  also  be  tried.  If  these  fail  instruments 
should  be  used.  The  treatment  is  dilatation  through  the  mouth  by 
means  of  large  bougies;  by  means  of  a  rubber  bag  attached  to  a 
tube,  and  distended  after  it  is  in  place;  or  by  means  of  a  special 
divulsor  introduced  through  the  esophagoscope.  In  the  worst  cases 
the  cardia  may  be  stretched  with  the  fingers  or  a  uterine  dilator, 
after  opening  the  stomach.  More  severe  operations,  e.g.,  division 
of  the  cardia  longitudinally  with  transverse  suture,  resection  of  the 
cardia,  esophagoplication  through  the  abdomen  or  thorax,  should 
very  rarely  be  indicated. 

Wounds  of  the  esophagus  from  without  have  already  been 
referred  to  under  cut  throat.  Internal  injuries,  e.g.,  from  foreign 
bodies,  bougies,  and  the  swallowing  of  caustics,  cause  painful  dyspha- 
gia, bleeding,  and  emphysema  if  the  wall  is  perforated.  The  patient 
is  fed  by  rectum  for  a  week  or  more,  and  sounds  used  when  healing 
has  occurred,  in  order  to  prevent  the  development  of  a  stricture. 
After  the  swallowing  of  a  caustic  the  proper  antidote  should,  of 
course,  be  administered. 


UPPER    DIGESTIVE    APPARATUS  659 

Foreign  bodies  in  the  esophagus  arc  most  frequent  in  children  and 
lunatics.  They  are  aj^t  to  be  arrested  at  the  narrowest  portions  of  the 
tube,  viz.,  opposite  the  cricoid  cartilage  (6  inches  from  the  teeth), 
at  the  level  of  the  left  bronchus  (12  inches  from  the  teeth),  and  at  the 
diaphragmatic  opening  (16  to  18  inches  from  the  teeth).  The  symp- 
toms are  dysphagia,  pain,  and  sometimes  dyspnea.  Sharp  or  rough 
bodies  may  cause  hemorrhage;  prolonged  impaction  may  lead  to  per- 
foration and  death.  Owing  to  the  irritation  which  isi)roduced,  the 
symptoms  sometimes  persist  for  a  time,  even  after  the  foreign  body 
has  been  removed.  Foreign  bodies  may  be  detected  with  the  bougie, 
with  the  esophagoscope,  or  if  dense,  with  the  X-ray  (Fig.  3  70) .  When 
lodged  in  the  cervical  portion  of  the  tube  external  palpation  may  be 
of  some  value.  The  patient  is  usually  able  to  indicate  the  site  of  im- 
paction.    The  best  treatment  is  extraction  under  the  eye  by  means  of 


Fig.  370. — Skiagraph  showing  location  of  penny  in  esophagus  above  a  stricture,  the 
result  of  swallowing  lye. 

long  slender  forceps  introduced  through  an  esophagoscope.  Of  193 
cases  of  esophagoscopy  for  foreign  bodies,  performed  by  skillful  opera- 
tors, the  foreign  body  was  removed  155  times,  and  escaped  into  the 
stomach  26  times.  Twelve  of  the  patients  died  (Jackson).  If  one 
has  no  esophagoscope,  or  no  skill  in  using  it,  and  the  patient  cannot 
be  sent  to  a  specialist,  one  of  the  older  methods  of  extraction  must  be 
selected  for  which  purpose  the  size,  shape,  situation,  and  nature  of  the 
body  should  be  ascertained  whenever  possible.  Bodies  like  pins  and 
fish  bones  may  be  extracted  with  the  expanding  horsehair  probe  (Fig. 
371)  discs  and  coins  with  the  coin  catcher  (Fig.  372).  Round  and 
smooth  objects  may  sometimes  be  pushed  into  the  stomach.  When 
in  the  cervical  portion  of  the  esophagus,  the  offending  substance 
may  often  be  removed  with  long  curved  forceps.  Esophagotomy  is 
indicated  when  a  body  is  impacted  in  the  upper  part  of  the  tube,  the 
esophagus  being  exposed  in  the  neck  as  described  in  the  treatment  of 
diverticula,   and   sutured   after  extraction  of   the    foreign   body. 


66o 


MANUAL    OF    SURGERY 


Impaction  in  the  lower  part  of  the  esophagus  may  demand  gastrot- 
omy,  and  extraction  of  the  foreign  body  by  the  finger  or  forceps  intro- 
duced through  the  cardiac  orifice  of  the  stomach.  The  mortality  of 
cutting  operations  for  foreign  bodies  in  the  esophagus  is  20  per  cent. 

Stricture  of  the  esophagus  may  be  (i)  inorganic  or  (2)  organic. 

I.  Inorganic  or  spasmodic  strictiu'e  (esophagismus)  is  usually 
hysterical  in  origin,  the  spasm  beginning  below  and  ascending  (globus 


Fig.  371. — Expanding 
horsehair  probang. 


Fig.  372. — -Coin- 
catcher. 


Fig.   373. — Esophageal 
bougies. 


hystericus) ,  but  occasionally  occurs  in  tetanus,  and  as  the  result  of 
reflex  irritation  in  diseases  of  the  larynx  (opposite  the  larynx),  liver, 
and  stomach  (at  the  cardia) .  In  the  last  situation  it  may  become 
permanent  and  give  rise  to  the  so  called  idiopathic  dilatation  of  the 
esophagus  (q.v.).  The  symptoms  are  sudden  in  onset,  intermittent 
in  character,  and  associated  with  evidences  of  the  causative  lesion. 
There  is  a  spasmodic  choking  sensation,  with  dysphagia  and  some- 
times regurgitation  of  food.     Anesthesia  relaxes  the  spasm  and  per- 


UPPER   DIGESTIVE    APPARATUS  66 1 

mits  the  i)assage  of  a  full-sized  bougie.  The  treatment  is  directed 
to  the  cause.  The  passage  of  bougies  will  do  more  harm  than  good 
in  hysterical  cases. 

2.  Organic  stricture  is  usually  (a)  cicatricial  or  (b)  malignant, 
although  it  may  be  congenital  or  be  caused  by  foreign  bodies  or  the 
pressure  of  aneurysms,  tumors,  etc.  (a)  Fibrous  or  cicatricial  stric- 
ture is  generally  the  result  of  the  swallowing  of  corrosives,  but  may 
follow  also  other  injuries  and  ulcerations.  It  is  most  frequent  in  the 
young  and  often  situated  opposite  to  the  cricoid  cartilage.  In  some 
cases  there  are  multiple  strictures. 

The  S5miptoms  come  on  slowly,  there  first  being  difficulty  in 
swallowing  solids  and  finally  in  swallowing  liquids.  When  the 
stricture  is  near  the  stomach,  food  may  not  be  returned  immediately 
but  may  collect  in  the  pouch  which  forms,  and  regurgitated  after  an 
interval,  the  reaction  being  alkaline,  not  acid  as  would  be  the  stomach 
contents.  Pain  is  slight  or  absent  and,  as  a  rule,  the  patient  is  able 
to  locate  the  site  of  obstruction.  In  the  later  stages  there  is  marked 
emaciation  from  starvation.  The  diagnosis  is  confirmed  and  the 
stricture  located  wdth  an  esophageal  bougie  (Fig.  373),  which  in  the 
adult  should  normally  enter  the  stomach  16  to  18  inches  from  the 
teeth.  The  patient  is  seated  with  the  head  forward  and  the  jaws 
open;  the  bougie  is  warmed,  lubricated  with  glycerin,  and  passed 
downward  into  the  esophagus  while  the  left  forefinger  depresses  the 
tongue  and  guards  the  orifice  of  the  larynx.  Great  force  should 
never  be  employed,  particularly  if  cancer  is  suspected,  as  perforation 
and  death  may  follow.  Furthermore,  it  is  well  to  rule  out  the  pres- 
ence of  aneurysm  before  passing  a  bougie.  In  all  cases  there  is  a 
delay  in  the  swallowing  sound,  which  is  normally  about  four  seconds 
in  length,  i.e.,  from  the  time  the  patient  begins  to  swallow  a  mouthful 
of  water  until  the  last  gurgle  into  the  stomach  is  heard;  the  ear  is 
applied  to  the  vertebral  groove  near  the  angle  of  the  left  scapula. 
Finally  the  esophagoscope  may  be  used  to  determine  the  nature  and 
site  of  the  stricture,  and  the  seat  of  narrowing  may  be  graphically 
depicted  by  a  radiogram,  after  the  ingestion  of  bismuth. 

The  treatment  is  gradual  dilatation  by  passing  increasing  sizes  of 
bougies  every  second  or  third  day.  In  order  safely  to  penetrate  a 
minute  stricture,  a  filiform  bougie  may  be  inserted  under  direct  in- 
spection through  the  esophagoscope.  Plummer  has  the  patient  swallow 
sLx  yards  of  fine  silk,  three  in  the  evening  and  three  the  following 
morning.  The  portion  first  swallowed  passes  into  the  intestine,  so 
that  the  thread  hanging  from  the  mouth  may  be  pulled  taut.  A 
bougie  with  a  perforated  olive  tip  is  then  threaded  on  the  silk,  which 


662  *  MANUAL    OF    SURGERY 

acts  as  a  guide  to  the  orifice  of  the  stricture.  In  cases  in  which 
dilatation  cannot  be  practised  a  Symond's  tube  may  be  used.  This  is 
a  rubber  tube,  funnel-shaped  at  the  upper  end  where  it  rests  against 
the  stricture.  It  is  inserted  by  a  whalebone  introducer,  and  removed 
every  two  or  three  weeks  by  means-of  a  piece  of  silk  attached  to  its 
upper  end  and  issuing  from  the  mouth.  Retrograde  dilatation  by 
means  of  the  linger  or  bougie  may  be  practised  after  opening  the 
stomach  when  the  lesion  is  near  the  cardiac  orifice.  Abbe's  operation 
is  applicable  to  strictures  in  the  thoracic  portion  of  the  esophagus 
which  have  resisted  other  means  of  treatment.  A  shot  clamped  to 
the  end  of  a  fine  piece  of  silk  is  swallowed  by  the  patient.  The 
stomach  is  then  opened  and  coarse  silk  attached  to  the  thread  and 
pulled  through  the  stricture,  which  is  then  divided  by  sawing  move- 
ments, while  it  is  made  tense  by  the  pressure  of  a  bougie  passed  from 
below.  In  some  cases  the  silk  is  brought  out  through  an  esophago- 
tomy  wound  in  the  neck  instead  of  through  the  mouth.  The  calibre 
of  the  esophagus  is  maintained  by  the  passage  of  bougies.  Ochsner  's 
method  consists  in  opening  the  stomach,  and  passing  a  long  loop  of 
silk  through  the  stricture  by  means  of  a  whalebone  probe.  A  small 
rubber  tube  is  passed  through  this  loop,  and  drawn  through  the  stric- 
ture while  on  the  stretch.  When  released  the  rubber  swells  and 
dilates  the  stricture.  Increasing  sizes  of  tubes  are  thus  employed. 
Internal  esophagotomy  by  means  of  an  instrument  with  a  concealed 
kniie,  forcible  dilatation  by  special  divulging  instruments,  and  electro- 
lysis have  been  successfully  utilized  with  the  aid  of  the  esophago- 
scope.  External  esophagotomy  has  been  employed  in  high  strictures, 
the  contraction  being  divided,  dilated,  or  even  excised.  Esophagos- 
tomy  consists  in  suturing  the  mucous  membrane  of  the  esophagus 
below  the  stricture  to  the  skin,  thus  making  an  artificial  mouth. 
Gastrostomy  is  indicated  when  swallowing  is  impossible,  in  order  to 
feed  the  patient.  A  stricture  which  is  thus  rested  may  after  a  time 
become  passable  to  bougies.  If  the  stricture  remains  impermeable 
esophago plasty  (vide  infra)  may  be  tried. 

(b)  Malignant  stricture  is  most  frequent  in  men  after  the  age  of 
forty,  and  most  comrnon  at  the  narrowest  portions  of  the  esophagus, 
viz.,  opposite  the  cricoid,  at  the  level  of  the  left  bronchus  (being 
epitheliomatous  in  both  instances),  and  at  the  cardia,  when  it  is  a 
columnar-celled  carcinoma.  The  symptoms  are  those  of  cicatricial 
stenosis,  but  there  are  greater  pain,  more  rapid  emaciation,  and 
often  cough,  and  regurgitation  of  blood-stained  food.  The  tumor 
may  be  felt  when  the  cervical  portion  is  involved.  Other  symptoms 
mav  arise  owing  to  invasion  of  surrounding  structures.     As    the 


UPPER    DIGESTIVE    API'ARATUS  663 

a])i)caranccs  of  carcinoma  are  distinctive,  the  diagnosis  may  be 
made,  even  in  the  earliest  stage,  by  means  of  the  esophagoscope,  a 
bit  of  tissue  being  removed  for  microscopic  corroboration;  and  since 
resection  of  the  esophagus  has  been  successfully  performed,  early 
diagnosis  is  essential,  if  more  patients  are  to  be  saved.  The  bougie 
and  the  X-ray  are  valuable  only  in  the  later  stages,  for  determining 
the  site  of  the  stricture,  but  are  incompetent  to  establish  definitely 
its  carcinomatous  nature.  Moreover,  since  the  bougie  is  blind  and  a 
carcinomatous  stricture  often  friable,  esophageal  sounding  is  attend- 
ed by  greater  danger  than  exploration  under  the  guidance  of  the  eye. 
The  treatment  in  the  early  stages  is  generally  the  passage  of  a  soft 
rubber  bougie  to  keep  the  canal  open.  Symond's  tube  has  been 
used  in  some  cases.  The  insertion  of  a  capsule  of  radium  through 
the  esophagoscope  is  a  palliative  measure  of  some  value.  Gartros- 
tomy,  which  permits  the  patient  to  be  fed  and  puts  the  esophagus 
at  rest,  should  not  be  postponed  until  swallowing  is  impossible,  but 
should  be  preformed  as  soon  as  the  dysphagia  becomes  pronounced. 
Esophagectomy  should,  we  believe,  be  recommened  in  suitable  cases. 
Esophagectomy  for  a  growth  limited  to  the  cervical  portion  of  the 
gullet  has  been  performed  successfully  a  number  of  times.  In  one 
case  we  removed  the  cervical  esophagus,  the  larynx,  the  trachea 
as  far  as  the  manubrium,  and  the  thyroid  gland.  Excision  of  the 
thoracic  portion  of  the  esophagus  has  been  attempted  extrapleurally, 
after  resecting  a  portion  of  several  ribs  near  the  spine,  but  more 
room  can  be  obtained  by  the  transpleural  route,  the  operation 
being  conducted,  in  order  to  prevent  collapse  of  the  lung,  with  the 
aid  of  differential  pressure  (positive  or  negative),  or,  better,  with  the 
aid  of  intratracheal  insufflation  anesthesia.  Efforts  to  anastomose 
the  esophageal  segments  left  after  excision  of  the  growth,  or  to 
anastomose  the  upper  segment  with  the  stomach,  have  resulted  in 
failure.  Torek's  patient,  who  is  still  living  eighteen  months  after 
excision  of  the  thoracic  esophagus,  was  operated  upon  in  two  stages 
A  gastrostomy  was  first  performed.  At  the  second  operation  a  cut 
was  made  through  the  entire  length  of  the  seventh  left  intercostal 
space,  thence  upwards  through  the  seventh,  sixth,  fifth,  and  fourth 
ribs,  between  their  angles  and  tubercles.  A  rib  spreader  was  placed 
between  the  seventh  and  the  eighth  ribs,  the  esophagus  separated  by 
blunt  dissection,  cut  at  each  end  between  ligatures,  and  removed. 
The  upper  end  was  brought  out  at  the  base  of  the  neck,  the  lower 
end  invaginated.  The  chest  was  closed  by  passing  sutures  around 
the  seventh  and  the  eighth  ribs,  the  lung  being  fully  inflated  before 
the  last  stitch  was  tied.     Zaaijer  and  Ach  have  successfully  excised  a 


664  MANUAL    OF    SURGERY 

carcinoma  of  the  cardia.  Zaaijer  first  established  a  gastrostomy.  In 
the  second  stage  he  resected  a  number  of  ribs  so  as  to  allow  the 
thoracic  wall  to  collapse,  thus  lessening  the  distance  to  the  growth. 
At  the  third  operation  the  pleural  and  the  peritoneal  cavities  were 
opened,  the  diaphragm  was  split  up  to  the  hiatus,  the  growth  re- 
moved between  clamps,  the  stomach  closed,  and  the  lower  end  of  the 
esophagus  sutured  to  the  skin  near  the  posterior  axillary  line.  After 
operations  of  this  character  food  may  be  led  from  the  lower  end  of 
the  remaining  portion  of  the  esophagus  to  the  opening  in  the  stomach 
by  means  of  a  rubber  tube,  or  an  artificial  esophagus  may  be  con- 
structed as  described  in  the  next  section. 

Esophagoplasty,  or  the  formation  of  an  atificial  esophagus  may 
be  tried  in  cases  of  impassable,  inoperable,  cicatricial  stricture  of  the 
esophagus,  or  in  cases  in  which  the  esophagus  has  been  resected. 
The  skin  between  the  esophageal  and  the  gastric  fistulae  may  be 
fashioned  into  a  tube,  the  outer  surface  of  which  is  covered  with 
flaps  from  the  chest  (Bircher).  The  upper  part  of  the  jejunum 
(Roux)  or  the  transverse  colon  (Kelling,  Vulhet)  may  be  isolated, 
except  for  the  mesenteric  attachment,  and  drawn  up  beneath  the 
the  skin  of  the  thorax,  the  lower  end  of  the  transplanted  intestine 
being  anastomosed  with  the  stomach,  the  upper  with  the  stump  of  the 
esophagus.  Hirsch  suggests  employing  the  anterior  wall  of  the 
stomach,  Jianu  the  whole  length  of  the  greater  curvature;  in 
these  methods  one  end  of  the  new  esophagus  is  already  attached  to 
the  stomach.  Fink  proposes  severing  the  pylorus,  drawing  it  up 
beneath  the  thoracic  skin,  and  performing  posterior  gastroenter- 
ostomy. Intra-instead  of  antethoracic  transplantation  of  a  segment 
of  the  stomach  or  the  intestine  also  is  a  possibility. 


CHAPTER  XXVII 
ABDOMEN 

The  postures  different  operations  may  require  and  the  situation 
of  the  incisions  for  exposure  of  various  organs,  are  given  with  the 
description  of  the  operations  on  the  viscus  concerned.  In  order  to 
give  an  idea  of  the  way  in  which  the  abdomen  is  opened  and  closed, 
we  shall  here  describe  only  the  median  incision,  since  it  is  often 
selected,  not  only  because  it  avoids  the  larger  nerves  and  blood 
vessels,  but  also  because  it  permits  exploration  of  both  sides  of  the 
abdominal  cavity.  When  it  is  necessary  to  pass  the  umbihcus,  the 
left  side  is  chosen  to  avoid  the  round  Hgament  of  the  liver,  although 
some  operators  excise  the  umbihcus  because  it  is  difhcult  to  sterilize 
and  to  suture.  After  incising  the  skin  and  subcutaneous  tissues, 
instead  of  locating  the  linea  alba  with  nicety,  the  anterior  sheath  of 
the  rectus,  usually  the  right,  is  spHt  longitudinally  a  short  distance 
from  the  median  line,  the  muscular  fibres  separated  with  the  finger 
or  the  handle  of  the  knife,  and  the  posterior  sheath  and  transver- 
saHs  fascia  divided.  Thus  are  presented  several  layers  of  tissue 
giving  broad  apposition  for  subsequent  union,  instead  of  the  single 
aponeurotic  layer  formed  by  the  linea  alba.  The  peritoneum,  which 
is  recognized  by  the  presence  of  fatty  tissue  in  front  of  it,  is  elevated 
from  the  viscera  with  forceps  and  opened  sufficiently  to  admit  the 
finger,  which  guards  the  intestines  while  the  opening  is  enlarged  with 
the  scissors.  After  the  intraperitoneal  manipulations  have  been 
completed  the  wound  is  closed  with  great  care  in  order  to  prevent 
the  development  of  a  hernia.  Buried  sutures  should  be  of  catgut, 
sutures  which  are  subsequently  removed,  of  silkworm  gut.  Through 
and  through  sutures,  which  are  introduced  about  one-fourth  inch 
from  the  edge  of  the  wound  and  about  one-half  inch  apart,  obHterate 
all  dead  spaces,  stop  oozing,  give  firm  support,  and  permit  rapid 
work.  Suture  of  the  individual  layers  of  the  abdominal  wall  is 
anatomically  more  accurate,  and,  owing  to  the  smaller  amount  of 
tension  on  each  suture,  less  apt  to  cause  necrosis.  The  various  ways 
of  closing  the  skin  incision,  when  the  tier  suture  is  employed,  are 
given  in  the  chapter  on  "Wounds".  The  author,  whenever  possible, 
puts  a  purse-string  suture  of  catgut  in  the  peritoneum,  thus  making  a 
dot  instead  of  a  line  of  scar  tissue  and  lessening  the  chances  of  adhes- 

66s 


666  MANUAL    OF    SURGERY 

ions;  the  suture  is  tied,  and  the  needle  passed  from  within  outwards 
through  the  muscle  and  its  anterior  sheath  and  temporarily  laid  aside; 
through  and  through  sutures  of  silkworm  gut  are  passed  through  all 
the  layers  except  the  peritoneum;  the  anterior  sheath  of  the  rectus  is 
closed  with  a  continuous  suture,  using  the  same  thread  that  was 
placed  in  the  peritoneum,  thus  drawing  the  peritoneum  up  under  the 
muscle  and  preventing  the  formation  of  a  dead  space;  and  finally 
the  silkworm-gut  sutures  are  tied.  In  the  upper  abdomen  the  perito- 
neum tears  so  easily  that  the  purse-string  suture  is  inapplicable.  In 
this  region,  therefore,  the  peritoneal  suture  should  include  a  portion 
of  the  muscle  and  be  applied  in  the  direction  of  the  wound  in  the 
abdominal  wall.  The  wound  is  dressed  with  aseptic  gauze,  retained 
in  place  by  adhesive  plaster  and  a  firm  binder.  The  patient  is  not 
allowed  to  sit  up  for  from  ten  days  to  three  weeks  or  longer,  according 
to  the  situation  and  length  of  the  incision  and  the  presence  or  absence 
of  drainage  or  infection.  In  most  instances  the  patient  should  wear 
an  abdominal  support  for  a  week  or  two  after  leaving  bed,  or,  if 
the  wound  has  healed  by  second  intention,  for  a  year,  when  the  scar 
may  be  inspected  for  bulging,  and  the  support  discarded  if  no  hernia 
be  found. 

The  indications  for  abdominal  section  {celiotomy,  laparotomy), 
in  order  to  deal  with  particular  affections  of  the  various  intraperi- 
toneal organs,  are  given  on  the  pages  devoted  to  the  surgery  of 
these  organs.  Often,  however,  the  surgeon  who  is  confronted  by 
a  patient  with  abdominal  symptoms  finds  that  he  is  unable  to  make 
a  precise  anatomic  and  pathologic  diganosis,  and  is  forced  to  be 
content  if  he  can  decide  whether  or  not  an  operation  is  necessary, 
when  it  should  be  performed,  and  where  to  make  his  incision  in 
the  abdominal  wall. 

Immediate  abdominal  section  to  save  life  may  be  demanded 
to  control  hemorrhage,  to  combat  infection,  or  to  relieve  obstruction. 

Hemorrhage  due  to  traumatism  may  arise  after  contusions  of 
the  abdomen  which  rupture  one  or  more  of  the  viscera  or  important 
blood  vessels,  after  penetrating  wounds,  and  after  abdominal 
operations.  Nontraumatic  hemorrhage  may  result  from  the  rupture 
of  an  aneurysm,  a  hematoma  of  the  ovary,  the  tube  in  ectopic 
pregnancy,  the  uterus  during  labor,  or  an  enlarged  spleen  in  typhoid 
fever. 

Infection  can  often  be  prevented  by  timely  operation,  notably 
in  cases  of  abdominal  injury  which  cause  extravasation  of  the 
contents  of  a  hollow  viscus  or  extrusion  of  the  viscera  through  the 
abdominal  wall,  and  in  cases  of  pathologic  perforation  of  a  hollow 


ABDOMEN  667 

viscus  (stomach,  inlcstinc,  gall  bladder,  urinary  bladder).  It  is 
in  the  stage  of  contamination,  i.e.,  during  the  first  few  hours  after 
the  accident  or  the  perforation,  that  the  surgeon  must  act  to  secure 
the  best  results.  After  twelve  hours,  and,  more  emphatically, 
after  24  hours,  the  infection  (peritonitis)  has  become  well  established, 
and  the  chance  of  survival  greatly  diminished.  In  another  group 
of  cases  the  infection  has  already  occurred,  but  is  confined  to  a 
single  organ  (appendix,  Meckel's  diverticulum)  or  circumscribed 
by  adhesions  or  inflammatory  tissue  (acute  abscess  within  or  behind 
the  peritoneum).  In  these  cases  early  operation  may  prevent 
extension  of  the  infection.  Although  acute  pancreatitis  may  be 
of  a  chemical  rather  than  of  a  bacterial  nature,  and  acute  hemato- 
genous infection  of  the  kidney  requires  a  lumbar  incision  rather 
than  celiotomy,  both  of  these  affections  should  be  mentioned  among 
abdominal  emergencies,  because  the  first  often  causes  widespread 
fat  necrosis  of  the  omentum  and  meserrtery,  and  the  second  is 
frequently  confused  with  intraperitoneal  lesions,  especially  appen- 
dicitis. 

Acute  obstruction  of  the  intestine,  including  strangulated  hernia; 
of  the  stomach  (volvulus);  of  the  blood  vessels,  e.g.,  in  thrombosis 
or  embolism  of  the  mesenteric  vessels,  volvulus  of  the  omentum, 
ovarian  cyst  or  floating  kidney  with  twisted  pedicle;  or  of  the  ureter 
of  an  only  existing  or  active  kidney  (obstructive  anuria)  must  be 
operated  upon  at  once. 

Delayed  abdominal  section  may  be  advisable  in  two  groups  of 
cases.  In  the  first  the  lesion  is  relatively  benign,  and  the  operation 
may  be  arranged  to  suit  the  convenience  of  the  patient  and  the 
surgeon.  Indeed,  in  some  instances,  e.g.,  reducible  hernia,  the 
patient  may,  with  reason,  decide  on  nonoperative  treatment.  In 
a  second  group  of  cases  the  operation  is  postponed  in  order  to  secure 
a  more  favorable  opportunity  for  intervention.  The  cases  in  this 
group  may  be  considered  under  the  three  headings  of  hemorrhage, 
infection,  and  obstruction. 

Acute  hemorrhage  into  the  stomach,  e.g.,  from  an  ulcer,  is  rarely 
an  indication  for  immediate  celiotomy,  since  the  bleeding  often 
ceases  spontaneously,  at  least  for  a  time,  and  the  operation  can  be 
more  safely  performed  after  the  patient  has  recovered  from  the 
effects  of  the  sudden  loss  of  blood.  Chronic  hemorrhage  from  any 
organ  requires  careful  investigation  to  determine  its  nature,  and 
then  prompt  operation,  if  the  condition  is  amenable  to  operation. 

Acute  infection  which  tends  to  become  subacute  or  chronic,  e.g., 
acute   cholecystitis,   acute   salpingitis  and   ovaritis,   is  usually  not 


668  MANUAL    OF    SURGERY 

attacked  surgically  until  it  becomes  quiescent,  hence  less  virulent. 
The  chief  concern  in  these  cases  is  that  of  mistaking  an  infection 
that  often  extends  for  one  that  generally  localizes  or  subsides,  e.g., 
a  perforated  duodenal  ulcer  for  acute  cholecystitis,  an  appendicitis 
for  a  salpingitis.  Chronic  infections,  e.g.,  of  the  gall  bladder, 
appendix,  and  Fallopian  tube,  should,  if  possible,  be  dealt  with  before 
they  cause  acute  symptoms  or  troublesome  complications.  The 
same  may  be  said  of  chronic  infections  like  tuberculous  peritonitis, 
tuberculosis  of  the  cecum,  and  actinomycosis  of  the  cecum. 

Acute  transient  obstruction  of  the  biliary  ducts  (hepatic  colic) 
or  of  the  ureter  (renal  colic)  is  treated  medically,  operation,  if 
necessary,  being  deferred  to  a  later  period.  Chronic  obstruction 
of  these  ducts  or  of  any  portion  of  the  gastrointestinal  canal  seldom 
necessitates  an  emergency  operation,  although  the  obstruction 
should  be  removed  at  an  early  period. 

Unnecessary  abdominal  section  is  sometimes  impossible  to 
avoid,  especially  in  the  presence  of  alarming  symptoms  which  might 
be  due  to  hemorrhage,  peritonitis,  or  obstruction.  The  prominent 
features  of  these  affections,  viewed  collectively,  are  pain,  tenderness, 
muscular  rigidity,  vomiting,  constipation,  and  tumor,  with  shock 
or  fever,  yet  one  or  more  of  these  features  may  exist  in  various 
maladies  that  do  not  demand  laparotomy. 

The  affections  of  the  abdominal  wall  that  may  simulate  intra- 
peritoneal lesions  are  muscular  soreness  from  coughing,  myositis, 
herpes  zoster,  neuritis,  and  neuralgia.  Operable  conditions  of  the 
abdominal  wall,  e.g.,  tumors,  and  abscesses,  are  of  less  importance, 
from  our  present  standpoint,  because  they  should,  in  any  event,  be 
treated  surgically.  Sometimes,  however,  a  parietal  abnormality 
may  be  completely  overlooked,  thus  in  a  small  epigastric  hernia  the 
pain  and  indigestion  may  be  erroneously  attributed  to  disease  of  the 
stomach  or  gall  bladder,  and  in  incipient  inguinal  hernia  to  disease 
of  the  appendix. 

The  affections  of  the  intraperitoneal  and  retroperitoneal  structures 
that  have  caused  error  are  acute  gastrectasia,  which  very  rarely 
requires  operation;  cardiospasm;  acute  irritation  or  inflammation 
of  the  stomach  or  intestines,  e.g.,  from  "indigestion,"  parasites, 
poisons  (including  ptomain  poisoning,  morphinism,  and  lead  poison- 
ing), dysentery,  typhoid  fever,  angioneurotic  edema,  and  Henoch's 
purpura;  mucous  colitis;  constipation;  fecal  impaction;  unimpacted 
foreign  bodies  in  the  intestine;  cirrhosis  of  the  liver,  with  pain  and 
swelHng  in  the  region  of  the  gall  bladder,  jaundice,  hematemesis, 
melena,   or  ascites,  thus  resembling  gall  stones,  gastric   ulcer,   or 


ABDOMEN  669 

tuberculous  peritonitis,  with  which  conditions,  indeed,  hepatic 
cirrhosis  is  sometimes  associated  (cirrhosis  of  the  Hver  is  occasionally 
operated  upon,  as  will  be  noted  later);  cardiac  liver,  i.e.,  the  large, 
painful,  perhaps  pulsating  liver  due  to  chronic  valvular  disease  of 
the  heart;  splenomedulary  leukemia;  normal  pregnancy,  because 
of  the  tumor,  the  vomiting,  and  sometimes  pain;  abortion,  which 
the  patient  may  attempt  to  conceal,  or  which  may  be  confused  with 
ectopic  pregnancy;  dysmenorrhea;  pelvic  cellulitis,  which,  as  a  rule, 
should  not  be  operated  upon,  unless  of  the  suppurative  variety; 
epididymitis;  inflammed  undescended  testicle,  unless  suppurative 
or  gangrenous;  vesiculitis;  Addison's  disease,  in  which  there  may 
be  vomiting,  constipation,  and  abdominal  pain;  chronic  nephritis 
leading  to  uremia,  which  may  be  associated  with  abdominal  pain, 
tympanitis,  and  vomiting  (more  often  the  opposite  mistake  is  made, 
i.e.,  an  old  lady  with  vomiting  and  oliguria  is  treated  for  uremia 
when  the  causative  lesion  is  a  small  strangulated  femoral  hernia) ; 
ectopic  or  pelvic  kidney;  pyelitis;  operable  lesions  of  the  kidney  and 
ureter,  which,  not  infrequently,  are  mistaken  for  intraperitoneal 
disease;  distended  urinary  bladder;  enlarged  retroperitoneal  lymph 
glands,  e.g.,  ,  from  Hodgkin's  disease,  leukemia,  typhoid  fever 
syphilis,  tuberculosis  (tabes  mesenterica) ,  or  metastatic  tumors, 
especially  metastases  from  malignant  disease  of  the  testicle  and 
lymphosarcoma  of  remote  regions  like  the  neck;  aneurysm  of  the 
aorta;  arteriosclerotic  colic  (abdominal  angina);  iliac  and  femoral 
phlebitis;  and  phantom  tumor. 

The  thoracic  diseases  that  may  cause  abdominal  symptoms  are 
pneumonia,  phthisis,  pleurisy  (including  diaphragmatic  pleurisy) 
angina  pectoris,  pericarditis,  dilatation  of  the  right  ventricle  of  the 
heart,  and,  as  mentioned  above,  endocarditis  which  leads  to  con- 
gestion of  the  liver. 

Diseases  of  the  spine,  especially  Pott's  disease,  often  produce 
symptoms  suggestive  of  intraabdominal  trouble. 

The  diseases  of  the  central  nervous  system  that  should  be  noted 
in  this  connection  are  brain  tumor  (vomiting),  cerebrospinal  men- 
ingitis (fever,  vomiting,  abdominal  pain,  and  rigidity),  abdominal 
crises  of  locomotor  ataxia,  neurasthenia,  and  hysteria. 

Finally  acute  general  infections,  like  influenza  and  small  pox, 
may,  because  of  pain,  vomiting,  and  fever,  be  mistaken  in  their 
early  stages  for  surgical  diseases  of  the  abdomen. 

The  technic  of  abdominal  section  follows  the  general  rules  already 
laid  down  in  chapter  iv,  to  which  the  student  is  referred  for  the 
details  concerning  the  preparation  and  after  care  of  the  patient. 


670  MANUAL    OF    SURGERY 

the  precautions  to  be  taken  in  order  to  avoid  leaving  instruments 
or  sponges  in  the  peritoneal  cavity,  and  the  indications  for  and  the 
dangers  of  drainage. 

Contusions  of  the  abdomen  vary  from  a  superficial  ecchymosis 
to  the  most  extensive  shattering  of  the  viscera.  Sudden  and  immedi- 
ate death  following  a  blow  on  the  abdomen,  without  gross  injury 
to  the  viscera,  has  been  attributed  to  shock,  or  disturbance  of  the 
solar  plexus,  but  is  probably  the  result  of  violence  to  the  heart  or 
to  its  nerve  mechanism.  Hematoma  and  suppuration  of  the  abdo- 
minal wall  may  follow  a  contusion  as  elsewhere.  Muscular  rupture 
follows  a  violent  force  to  a  normal  muscle  in  extreme  tension,  or  a 
trivial  injury  to  a  degenerated  muscle.  The  rectus  tends  to  rupture 
more  frequently  than  the  broad  muscles  of  the  parietes.  A  rup- 
tured muscle  should  be  sutured  because  of  the  subsequent  danger 
of  hernia.  When  a  blow  is  expected,  the  body  is  bent,  the  muscles 
contracted,  and  the  force  expended  on  the  abdominal  wall,  but  a 
blow  received  when  the  muscles  are  flaccid  is  very  apt  to  injure  the 
viscera.  The  most  serious  intraabdominal  injury  may  be  present 
without  any  evidence  of  injury  to  the  skin  or  muscles.  The  effects 
of  visceral  injury  are  manifested  immediately,  as  shock,  hemorrhage, 
or  peritonitis;  intermediately,  as  when  peritonitis  follows  a  per- 
foration through  a  contused  necrotic  patch  in  the  intestine,  the 
patient  having  been  apparently  well  for  one  or  more  days;  or  remotely, 
as  adhesions,  stricture  of  the  bowel,  aneurysm,  etc.,  developing  after 
a  prolonged  period.  In  all  cases  of  abdominal  injury  the  surgeon 
should  look  not  only  for  signs  of  shock,  internal  hemorrhage,  and 
peritonitis,  but  also  for  signs  of  gas  or  fluid  in  the  peritoneal  cavity, 
and  for  blood  in  the  vomitus.  urine,  and  bowel  movements,  as  well 
as  for  bleeding  from  the  vagina. 

Ruptures  of  most  of  the  large  intraabdominal  vessels  have  been 
recorded.  Providing  there  be  time,  the  abdomen  should  be  opened 
and  the  hemorrhage  checked.  If  the  vessel  be  severely  contused, 
bleeding  may  be  postponed  until  sloughing  of  the  arterial  wall  en- 
sues, or  thrombosis,  embolism,  stenosis,  or  aneurysm  may  develop, 
and  the  parts  suppUed  by  the  artery  may  become  gangrenous. 

From  its  elasticity  and  more  protected  position  beneath  the  ribs, 
the  stomach  is  less  hable  to  be  afifected  by  trauma  than  the  intestines. 
The  anterior  wall  is  the  most  frequent  site  for  rupture.  One  or  all 
the  coats  may  be  torn.  The  symptoms  are  those  of  shock  and  per- 
forative peritonitis.  Hematemesis  may  be  present  or  absent.  The 
stomach  should  be  sutured  and  the  treatment  for  peritonitis  insti- 
tuted. 


ABDOMEN  671 

Rupture  of  the  intestine  is  frequently  the  result  of  a  horse-kick,  a 
man-kick,  or  a  run-over  accident,  the  intestine  being  crushed  be- 
tween the  vulnerating  body  and  the  bony  parts  behind.  A  fall 
from  a  height  or  a  blow  upon  the  back  also  may  tear  the  intestine, 
particularly  where  it  is  iirmly  fixed,  e.g.,  the  duodenum.  7'he  most 
im]:)ortant  sjonptoms  are  pain,  tenderness,  rigidity  of  the  abdominal 
wall,  and  an  an.xious  facial  expression.  Shock  is  shght  or  absent  in 
25  per  cent,  of  the  cases.  Absence  of  liver  dulness  with  a  flat  abdo- 
men is  a  valuable  sign  of  pneumoperitoneum,  which  may  be  demon- 
strated also  by  the  X-ray.  Cellular  emphysema  is  rare  and  indicates 
a  lesion  of  the  bowel  beyond  the  limits  of  the  peritoneal  space. 
Movable  dulness  in  the  flanks  is  a  sign  of  fluid  in  the  peritoneal 
cavity,  which  may  be  serous,  sanguineous,  or  fecal.  Fecal  extravasa- 
tion is  rarely  great  in  rupture  of  the  bowel,  owing  to  the  contraction 
of  the  muscular  coat,  while  hemorrhage  is  slight  unless  the  mesentery 
or  other  vascular  structure  is  torn.  Abdominal  distention,  fever, 
and  other  symptoms  of  widespread  peritonitis  are  later  symptoms, 
and  usually  mean  that  the  favorable  time  for  operation  is  past. 
Vomiting  immediately  after  the  accident  is  unimportant,  but  recur- 
ring vomiting  is  ominous.  There  may  be  absence  of  peristalsis,  a 
friction  sound  on  auscultation,  and  sometimes  tenesmus  with  a 
frequent  desire  to  defecate.  Rectal  examination  in  some  instances 
may  detect  resistance  in  the  vicinity  of  the  rupture,  due  to  the  forma- 
tion of  adhesions  around  the  laceration.  Bright  blood  in  the  stools 
points  to  a  rent  in  the  large  bowel,  tarry  movements  to  a  lesion 
higher.  The  temperature,  pulse,  and  respirations  augment  with  the 
spread  of  the  peritonitis,  which  will  cause  also  a  leukocytosis  and  a 
rise  in  the  blood  pressure.  The  rectal  insufflation  of  hydrogen  or 
ether  to  detect  the  perforation  is  too  dangerous  to  be  employed. 

The  treatment  is  laparotomy  and  suture  of  the  perforation. 
Death  is  almost  inevitable  without  operation;  with  operation  20 
per  cent,  recover.  The  difficulty  is  to  make  an  early  diagnosis.  In 
the  presence  of  the  first  four  signs  mentioned  above,  exploration  is 
urgently  demanded.  As  a  rule  a  median  incision  is  made  below  the 
umbilicus,  and  the  rupture  found  between  the  seat  of  the  surface 
injury  and  the  spine;  the  possibility  of  more  than  one  perforation 
should  be  kept  in  mind  and  discolored  spots  treated  as  ruptures. 
Extravasation  of  blood  behind  the  peritoneum,  particularly  with  air 
crepitation,  may  be  due  to  retroperitoneal  rupture  of  the  colon  or 
duodenum.  Resection  or  extraperitoneal  isolation  of  the  injured 
bowel  (according  to  the  condition  of  the  patient)  may  be  indicated, 
because  of  the  severitv  of  the  contusion,  the  extent  of  the  laceration. 


672  MAXUAL    OF    SURGERY 

or  because  of  detachment  or  injury  of  the  mesentery.  Omental 
grafts,  held  in  place  with  sutures,  may  be  of  service  in  any  case  in 
which  it  is  feared  that  leakage  may  occur.  The  peritoneal  cavity 
should  be  cleansed,  and  closed  or  drained,  as  described  under  ''Pene- 
trating Wounds  of  the  Abdomen. " 

In  tears  of  the  omentum  and  mesentery  the  immediate  danger  is 
hemorrhage.  Later  an  inflammatory  mass  or  embarrassing  adhesions 
may  develop.  When  the  mesentery  is  \aolently  contused,  or  stripped 
from  the  bowel,  intestinal  gangrene  follows.  The  intestine  may 
become  strangulated  through  a  sHt  in  the  mesentery.  Sanguineous 
mesenteric  cysts  also  may  develop.  The  treatment  is  ligation  of  the 
bleeding  vessels,  and  excision  of  omentum  or  intestine,  if  such  be 
needed. 

The  liver  is  frequently  lacerated,  particularly  the  right  lobe.  One 
half  of  the  cases  die  within  twenty-four  hours  from  hemorrhage. 
Pain  is  severe  and  shock  profound,  and  there  are  symptoms  of 
internal  bleeding,  with  movable  dulness  in  the  flanks.  In  some 
cases,  probably  as  the  result  of  bihary  absorption,  the  pulse  is  slow 
instead  of  rapid.  Hepatic  dulness  is  increased.  Jaundice  some- 
times develops  after  twenty-four  hours,  and  bile  and  sugar  may  ap- 
pear in  the  urine.  Peritonitis  frequently  occurs  in  those  who  sur- 
vive the  initial  shock  and  subsequent  hemorrhage.  Operation  is 
imperative  to  check  hemorrhage,  which  may  be  controlled  by  suture, 
Hgature,  cautery,  or  tampon.  Sutures  should  be  given  the  prefer- 
ence; to  prevent  their  tearing  out  the  capsule  of  the  liver  may  be 
fortified  by  a  transplant  of  fascia,  but  if  they  fail  to  stop  the  bleeding, 
or  if  the  wound  is  so  situated  as  to  make  suturing  difficult,  the  wound 
may  be  stuft'ed  with  gauze,  or,  better,  with  omentum,  muscle,  or 
fat,  held  in  place,  when  possible,  with  a  few  sutures  of  catgut. 
Cauterization  is  not  suitable  for  large  wounds  and  is  hable  to  be 
followed  by  secondary  hemorrhage. 

Ruptures  of  the  gall-bladder,  cystic,  hepatic,  and  common  bile 
ducts  have  occurred.  The  symptoms  are  pain,  shock,  biliary  ascites 
and  later  in  some  cases  peritonitis,  as  the  bile  is  irritating  even  if 
sterile.  In  a  complete  rupture  of  the  hepatic  or  common  duct  there 
would  be  jaundice,  cholemia,  and  inanition.  The  gall-bladder  may 
be  sutured  or  removed,  according  to  the  degree  of  laceration.  Drain- 
age is  the  treatment  when  the  ducts  are  damaged,  although  in  a 
suitable  case  anastomosis  would  be  the  ideal  procedure. 

The  spleen  is  not  as  frequently  ruptured  as  the  Hver.  Enlarge- 
ment of  the  organ  predisposes  to  injury.  Hemorrhage  is  the  great 
danger,  but  is  not  as  quickly  fatal  as  one  would  suppose,  owing  to  the 


ABDOMEN  673 

elasticity  of  the  organ,  and  to  the  fact  that  the  blood  coagulates 
rapidly  because  of  the  large  number  of  leukocytes  present.  Abscess 
or  peritonitis  may  follow.  The  symptoms  are  those  of  internal 
hemorrhage,  with  pain  and  tenderness  over  the  spleen,  and  sometimes 
pain  in  the  left  shoulder,  indicating  irritation  of  the  phrenic  nerve 
endings  in  the  diaphragm.  Splenic  dulness  is  increased,  and  fre- 
quently does  not  disppear  when  the  patient  is  turned  on  the  right 
side,  because  the  blood  is  often  clotted.  Operation  should  be  im- 
mediate; its  nature  depends  upon  the  condition  of  the  patient  and  of 
the  spleen.  If  the  patient  has  lost  much  blood,  if  the  spleen  is  large 
and  extensively  adherent,  and  if  the  tear  is  favorably  situated,  suture 
with  a  transplant  of  fascia,  as  for  the  liver,  is  to  be  chosen.  If  the 
capsule  is  thin,  the  spleen  soft,  and  the  tear  unfavorably  situated, 
packing  with  gauze,  omentum,  muscle,  or  fat  is  to  be  considered. 
Ordinarily  a  large  laceration  in  a  normal  spleen  is  best  treated  by 
splenectomy.  Of  thirty-four  cases  of  splenectomy  for  rupture,  41.2 
per  cent,  were  fatal. 

The  pancreas  is  seldom  ruptured  alone.  In  the  absence  of  fatal 
hemorrhage,  gagrene,  suppuration,  or  chronic  pancreatitis  may  ensue. 
The  so-called  trumatic  cysts  of  the  pancreas  are  probably  collections 
of  blood  and  pancreatic  fluid  in  the  lesser  peritoneal  cavity,  the  fora- 
men of  Winslow  having  been  closed  by  adhesions.  The  symptoms 
are  those  of  shock  and  internal  hemorrhage.  The  bleeding  is  checked 
in  the  same  way  as  bleeding  from  the  liver,  or  by  partial  excision, 
being  careful  to  preserve  the  canal  of  Wirsung,  Posterior  drainage 
through  the  left  lumbar  fossa  is  to  be  employed,  to  drain  off  any 
leakage  of  pancreatic  juice,  which  may  cause  peritonitis  or  fat  necro- 
sis. 

The  kidney  is  well  protected  by  its  position  and  by  an  enveloping 
bed  of  fat,  yet  it  is  not  infrequently  injured.  The  rupture  is  usually 
transverse  to  the  long  axis  of  the  kidney.  If  the  capsule  remains 
intact,  hemorrhage  takes  place  into  the  organ;  if  it  is  torn,  blood  and 
urine  collect  in  the  perinephritic  tisues.  If  the  peritoneum  is  lacerated 
urine  and  blood  accumulate  in  the  abdominal  cavity.  Bilateral 
and  occasionally  unilateral  injuries  of  the  kidney  may  be  fatal  from 
anuria,  in  the  latter  instance  the  sound  kidney  refusing  to  act  from 
reflex  inhibition.  The  symptoms  are  shock,  pain,  and  hematuria. 
Hematuria  may  be  absent  if  the  kidney  is  separated  from  the  renal 
vessels  or  the  ureter,  or  if  there  be  a  clot  in  the  ureter,  or  an  extensive 
laceration  of  the  pelvis  of  the  kidney.  Absence  of  hematuria  has 
been  caused  also  by  thrombosis  of  the  renal  vessels  and  a  preexisting 
stricture  of  the  ureter.     Cystoscopy  in  these  cases  will  show  that  no 


674  MANUAL    OF    SURGERY 

urine  is  coming  from  (he  ureter  on  the  injured  side.  lirownish 
urine  coming  from  the  ureter  indicates  clotting  in  the  pelvis  of  the 
kidney.  Hemorrhage  and  sepsis  are  the  dangers.  Symptoms  of 
internal  hemorrhage,  with  an  increasing  tumor  in  the  loin,  demand 
immediate  exploration.  If  the  kidney  is  hopelessly  destroyed,  or  if 
ligation  of  the  renal  vessels  be  necessary  to  control  the  bleeding,  the 
organ  should  be  removed.  If  but  moderate  laceration  is  present, 
disinfection  and  drainage,  with  suture  or  partial  nephrectomy,  is 
indicated.  If  tamponage  is  chosen,  fat  or  muscle,  held  in  place 
with  a  few  sutures,  is  probably  superior  to  gauze  as  a  hemostatic 
agent.  Defects  in  the  pelvis,  if  too  large  for  simple  suturing,  may 
be  repaired  by  turning  down  a  flap  of  the  capsule,  or  by  transplanting 
a  piece  of  fascia.  The  possibility  of  injury  to  the  intraperitoneal 
organs  should  not  be  forgotten.  Mild  cases  are  treated  by  ice  to 
the  loin,  internal  astringents,  urinary  antiseptics,  and  rest. 

Rupture  of  the  ureter  is  caused  by  its  being  crushed  against  the 
transverse  process  of  the  third,  fourth,  or  fifth  lumbar  vertebra,  or 
by  traction  on  the  ureter.  All  ruptures  are  above  the  pelvic  brim. 
Shock  is  neither  profound  nor  persistent,  unless  there  be  some  injury 
to  the  other  abdominal  organs.  A  few  drops  of  blood  in  the  urine, 
with  persistent  pain  and  tenderness  in  the  side,  point  to  injury  of 
the  ureter.  If  the  duct  be  completely  ruptured,  cystoscopy  will 
reveal  no  urine  escaping  from  the  affected  ureter,  and  a  retroperi- 
toneal accumulation  of  urine  and  blood  will  appear  after  several 
days.  Complete  obstruction  of  the  ureter  will  cause  atrophy  of  the 
kidney;  partial  obliteration  may  result  in  a  pyo-  or  hydronephrosis. 
If  the  injury  be  uncomplicated,  the  danger  to  life  is  slight,  although 
there  is  little  tendency  towards  spontaneous  repair.  A  tear  in  the 
peritoneum  may  lead  to  a  fatal  peritonitis.  Immediate  anastomosis 
is  the  ideal  treatment.  Lumbar  incision  and  drainage  are  indicated 
after  infection  has  taken  place;  if  a  ureteral  fistula  follows  it  should 
be  treated  as  described  in  chap.  xxix. 

Rupture  of  the  bladder  is  extraperitoneal,  intraperitoneal,  or 
combined  extra-  and  intraperitoneal.  Laceration  of  the  mucous 
membrane  alone,  with  hematuria,  may  follow  a  blow  on  the  hypo- 
gastrium.  Extraperitoneal  rupture  is  usually  associated  with  fracture 
of  the  pelvis.  Intraperitoneal  rupture  is  generally  caused  by  a  forc- 
ing backward  of  the  distended  viscus  against  the  promontory  of  the 
sacrum,  although  in  some  cases  it  may  result  from  contre  coup.  In 
uncomplicated  cases  the  rent  is  vertical  and  occurs  at  the  upper  and 
posterior  part  of  the  bladder.  Normal  urine  may  come  in  contact 
with  the  peritoneum  without  causing  inflammation,  but  if  allowed  to 


ABDOMEN  675 

remain  or  if  bacteria  are  present  inflammation  quickly  ensues.  The 
injury  is  fatal  without  operation.  With  operation  over  one-half 
die  from  shock,  hemorrhage,  or  peritonitis.  The  symptoms  are 
shock,  hypogastric  pain,  a  sensation  of  something  having  given 
way,  rectal  tenesmus,  and  an  urgent  desire  but  inability  to  urinate. 
The  catheter  reveals  a  little  bloody  urine  or  no  urine  at  all;  it  may 
pass  directly  into  the  abdominal  cavity.  Cases  have  occurred  in 
which  unstained  urine  has  been  withdrawn  from  a  torn  bladder.  A 
measured  quantity  of  boric  acid  solution  may  be  injected  into  the 
bladder;  if  the  same  amount  returns,  the  bladder  is  probably  intact. 
Air  or  hydrogen  may  be  pumped  into  the  bladder,  and  if  the  viscus 
is  intact,  it  will  rise  above  the  pubes  as  a  symmetrical  tumor,  tympan- 
itic on  percussion,  and  the  air  will  rush  out  again  when  allowed  to 
do  so.  When  the  tear  involves  the  peritoneum,  the  gas  will  cause  a 
general  distention  of  the  belly;  when  the  rent  is  extraperitoneal,  an 
emphysema  of  the  extravesical  connective  tissue.  These  injection 
tests  are  not  infallible,  and  may  spread  infection.  Movable  dulness 
in  the  flanks  suggests  intraperitoneal  rupture,  unilateral  tenderness 
and  tumor  extraperitoneal  rupture.  A  differential  diagnosis  is, 
however,  unimportant  before  operation.  When  symptoms  of  rupture 
are  present,  the  prevesical  space  should  be  opened  through  a 
suprapubic  incision,  and  if  this  be  healthy,  indicating  the  absence 
of  extraperitoneal  rupture,  the  incision  may  be  continued  upwards 
and  the  abdominal  cavity  opened.  An  intraperitoneal  rupture 
should  be  sutured  and  the  peritoneal  cavity  cleaned  and  drained. 
As  a  rule  in  extraperitoneal  rupture,  drainage  is  all  that  can  be  done. 

Rupture  of  the  diaphragm  ( see  Diaphragmatic  Hernia) . 

Wounds  of  the  abdomen  may  be  penetrating  or  non-penetrating. 

Non-penetrating  woimds  should  be  excised,  the  fact  of  non- 
penetration  established  by  inspection,  and  the  divided  parts  sutured, 
especial  care  being  taken  to  approximate  the  severed  aponeuroses 
and  muscles,  in  order  to  guard  against  hernia.  If,  however,  there  are 
signs  of  intraabdominal  injury  particularly  after  blunt  violences  or 
a  gunshot  wound,  the  peritoneal  cavity  should  be  opened  and  ex- 
plored, since,  as  mentioned  above,  the  viscera  may  be  ruptured 
without  penetration  of  the  abdominal  wall. 

Penetrating  wounds,  including  those  produced  by  gunshots  and 
stabs,  are  readily  recognized  if  the  viscera  or  the  contents  of  the 
viscera  escape  through  the  wound.  The  symptoms  and  the  dangers 
of  visceral  injury  are  those  of  contusions  of  the  abdomen.  The 
treatment,  even  without  symptoms  of  visceral  injury,  is  laparotomy, 
in  order  to  explore  the  abdomen,  check  hemorrhage,  and  close  such 


676  MANUAL    OF    SURGERY 

viscera]  perforations  as  may  be  tound.     A  stab  wound  in  the  parieties 
should  be  excised.     If  the  omentum  protrudes  it  should  be  ligated 
and  removed;  if  the  intestine,  washed  with  salt  solution  and  replaced 
in  the  abdomen.     The  opening,  if  conveniently  situated  for  abdominal 
exploration,  may  then  be  enlarged  with  a  fresh  knife.     In  other  cases 
the  opening  left  by  the  excision  may  be  sutured,  and  the  exploration 
conducted  through  a  separate  incision  made  with  separate  instru- 
ments.    Gunshot  ivounds  are  treated  on  the  same  principles.     If  the 
missile  is  lodged,  the  X-ray  will  locate  it,  and  the  point  of  localization, 
when  considered  in  relation  to  the  wound  of  entrance,  will  give  the 
length  and  direction  of  the  track  of  the  bullet.     This  is  of  particular 
importance  when  the  external  wound  is  in  some  remote  region,  like  the 
chest,  the  loin,  or  the  buttock.     The  parietal  wound  of  entrance 
should  be  treated  as  directed  above  for  a  stab  wound.     The  extent 
of  the  damage  depends  on  the  course  of  the  bullet,  but  in  all  cases 
it  is  necessary  to  review  the  whole  of  the  small  intestine  since  the 
coils  are  mobile,  and,  owing  to  their  arrangement,  perforations  from 
a  single  missile  may  be  found  many  feet  apart.     Perforations  espe- 
cially  liable  to  be  missed  are  those  of  the  posterior  wall  of  the 
stomach  or  the  colon,  of  the  hepatic  and  splenic  flexures  of  the  colon, 
and  of  the  lower  sigmoid  and  upper  rectum,  hence  these  regions  must 
be  carefully  examined  when  lying  in  or  near  the  track  of  the  bullet. 
After  dealing  with  the  lesions  of  the  individual  organs,  as  just  out- 
lined under  "Contusions  of  the  abdomen,"  the  peritoneal  cavity 
should  be  cleared,  by  sponging,  of  any  blood  or  extra vasated  visceral 
contents  which  may  be  present.     Irrigation  with  hot  salt  solution 
is  favored  by  some  surgeons,  especially  when  there  is  much  fecal 
may  be  oation,  but  is  falling  more  and  more  into  disuse.     Drainage 
contaminmitted  if  the  peritoneal  cavity  can  be  left  grossly  clean  and 
dry,  but  if  there  is  still  some  oozing  of  blood,  an  established  peri- 
tonitis, much  contamination  by  fecal  leakage,  or  a  suture  line  through 
which  the  surgeon  fears  leakage  may  occur,  drainage  should  be  em- 
ployed.    Retroperitoneal  lesions  of  the  large  bowel  are  predisposed 
to  leakage,  hence  must  be  drained,  the  best  site  for  the  drain  being 
the  loin.     Unless  found  quickly  the  missile  should  be  disregarded. 
The  patient  should  receive  a  prophylactic  injection  of  tetanus  anti- 
toxin,   and,    if   necessary,    the   general   treatment   for   shock   and 
hemorrhage. 

In  the  first  months  of  the  European  war,  military  surgeons,  follow- 
ing the  experience  gained  in  previous  conflicts,  treated  abdominal 
injuries  by  rest,  morphia,  and  starvation.  The  resulting  mortality 
according  to  Wallace,  was  about  80  per  cent.,  most  of  those  recover- 


ABDOMEN  677 

ing  bein^  ])aticnts  without  \iscc'ral  injury.  Later,  when  the  battle 
line  became  stationary,  the  means  of  trans])ortation  more  ra])i(J,  and 
the  hospitals  further  advanced  toward  the  front,  many  of  the  patients 
were  received  at  a  sufficiently  early  period  to  permit  operation. 
According  to  Hull,  of  the  total  number  of  wounded  reaching  a  hos- 
pital, from  I  to  2  per  cent.,  suffered  from  abdominal  injury, 
and  20  per  cent,  of  these  were  moribund  on  arrival.  Of  those  subjected 
to  laparotomy  46  per  cent,  recovered,  the  recovery  rate  in  those  with 
wounds  of  the  hollow  viscera  being  35  per  cent.  From  the  foregoing 
it  may  be  concluded  that  a  solider  with  a  wound  of  the  abdomen 
should,  if  proper  facilities  are  available,  be  treated  exactly  like  a 
civilian  with  a  similar  wound  i.e.,  by  early  exploration.  Late  opera- 
tion, i.e.,  after  24  or  36  hours,  is  almost  invariably  useless  or  fatal, 
useless  if  the  patient  shows  no  signs  of  peritonitis,  fatal  if  he  does. 
Phantom  tumor  of  the  abdomen  generally  occurs  in  hysterical 
females.  It  is  due  to  either  a  localized  contraction  of  the  abdominal 
muscles,  usually  a  section  of  the  rectus,  or  a  tetanic  spasm  of  the 
intestine.  The  swelling  may  be  as  hard  as  bone,  but  as  a  rule  varies 
in  consistency  on  different  examinations,  and  disappears  under 
anesthesia,  with  gurgling  if  it  be  intestinal.  The  treatment  is  that 
of  hysteria. 

THE  UMBILICUS 

Inflammation  and  abscess  are  commonly  the  result  of  uncleanli- 
ness,  especially  after  separation  of  the  cord,  or  in  corpulent  adults  in 
whom  the  umbilicus  is  deep.  Eczema  likewise  is  observed.  Tetanus 
neonatorum  and  erysipelas  may  be  caused  by  infection  of  the  um- 
bilicus soon  after  birth.  Benign  and  malignant  tumors  may  occur 
in  this  region,  but  are  rare.  Among  the  cysts  may  be  mentioned  the 
dermoid,  sebaceous,  vitelline  (developing  from  an  unobliterated 
portion  of  the  vitelline  duct),  serous  (due  to  a  shutting  ofT  of  an 
empty  hernial  sac),  and  the  urachal.  The  last  are  caused  by  disteu' 
tion  of  an  unobliterated  portion  of  the  urachus,  which  normally 
extends  from  the  bladder  to  the  umbilicus;  they  are  properitoneal, 
median  in  situation,  sometimes  of  large  size,  and  may  open  both  into 
the  bladder  and  at  the  umbilicus.  The  treatment  of  cysts  is  excision. 
In  some  urachal  cysts  this  is  not  possible,  and  incision  and  drainage 
are  all  that  can  be  accomplished. 

UmbiHcal  fistulae  may  be  congenital  or  acquired.  Fecal  fistulce 
resulting  from  non-closure  of  the  omphalo-mesenteric  duct  (Meckel's 
diverticulum)  are  first  observed  after  the  umbilical  stump  has 
separated.     The  mucous  membrane  may  become  everted  and  form 


678  AIAXUAL    OF    SURGERY 

a  red  tumor,  which  has  been  called  a  polypus  or  adenoma  when  the 
communication  with  the  intestine  has  become  obliterated.  When 
the  duct  is  wide  and  short  a  portion  of  the  intestine  may  protrude 
through  the  opening.  Fecal  fistulae  in  the  new-born  have  been 
caused  also  by  including  within  the  ligature  which  surrounds  the 
cord  a  small  umbilical  hernia.  Acquired  fecal  listuLT  follow  condi- 
tions like  strangulated  hernia  and  tuberculous  peritonitis.  Urinary 
jistulcB  are  caused  by  non-obliteration  of  the  urachus,  mucous  fisttdce 
by  the  omphalo-mesenteric  duct  or  the  urachus  which  has  become 
closed  at  the  visceral  end.  These  fistulae  should  be  excised  and  the 
opening  into  the  viscus  closed.  A  biliary  fistula,  following  perfora- 
tion of  the  gall  bladder,  is  occasionally  seen  at  the  umbilicus.  It 
should  be  excised  and  the  diseased  gall  bladder  drained  or  removed 
after  extracting  any  stones  that  may  be  present.  Umbilical  sinuses 
are  the  result  of  abscesses,  and  require  incision  and  packing. 
Umbilical  hernia  (see  Hernia). 

THE  PERITONEUM,  OMENTUM,  AND  MESENTERY 

Peritonitis,  or  inflammation  of  the  peritoneum,  is  practically 
always  bacterial  in  origin.  It  is  divided  primarily  into  the  acute  and 
chronic  forms. 

Acute  peritonitis  is  caused  by  perforations  of  the  hollow  viscera, 
wounds  of  the  abdomen,  extension  of  inflammatory  processes  from 
the  abdominal  organs  by  contiguity  or  continuity  (e.g.,  from  the 
Fallopian  tubes),  and  by  infection  coming  through  the  blood  or 
lymph  vessels.  Idiopathic  peritonitis  does  not  exist;  rheumatic 
peritonitis  probably  seldom  or  never  occurs.  A  great  variety  of 
micro-organisms  have  been  cultivated  from  cases  of  peritonitis,  and 
in  most  instances  the  infection  is  a  mixed  one.  The  streptococcus 
pyogenes  is  responsible  for  the  most  severe  forms;  the  staphylococcus 
pyogenes  is  less  virulent.  The  colon  bacillus  is  usually  found  in 
cases  secondary  to  intestinal  lesions.  The  diplococcus  of  pneumonia 
and  the  gonococcus  are  much  less  virulent  in  this  situation  than  are 
other  organisms.  Two  forms  of  acute  peritonitis  are  described, 
(i)  the  localized,  and  (2)  the  diffuse,  or  generalized. 

I .  Acute  localized  peritonitis  is  most  frequent  in  the  vicinity  of 
the  gall  bladder,  the  Fallopian  tubes,  and  the  appendix.  There  is  a 
subperitoneal  collection  of  round  cells,  and  the  peritoneum  becomes 
congested,  looses  its  luster,  sheds  its  endothelium  (especially  in  viru- 
lent infections),  and  exudes  a  sero-fibrinous  material,  which  surrounds 
the  aft'ected  area,  and  which  may  become  purulent,  forming  a  local- 


ABDOMEN  679 

izcd  abscess.  'Vhv  i)us  may  break  through  tin-  barrier  of  adhe- 
sions and  cause  a  generalized  peritonitis,  or  it  may  break  into  one  of 
the  hollow  viscera.  In  rare  cases  it  points  externally,  and  in  a  few- 
instances  in  which  it  is  well  encapsulated,  it  becomes  inspissated  or 
even  calcareous.  The  fibrinous  material  which  glues  adjacent 
peritoneal  surfaces  together  may  be  absorbed,  or  become  organized 
into  fibrous  adhesions.  The  symptoms  are  localized  pain,  tender- 
ness, and  muscular  rigidity,  with  fever,  increase  in  the  pulse  rate, 
vomiting,  and  constipation.  Later  the  inflammatory  mass  may 
be  palpated,  giving  either  a  dull  or  tympanitic  note  on  percussion. 
When  near  the  surface,  redness  and  edema  of  the  abdominal  wall 
may  be  noted.  Unless  the  infection  is  well  encapsulated,  leukocyto- 
sis is  present.  The  treatment  is  given  under  the  conditions  w-hich 
give  rise  to  the  localized  peritonitis,  as  it  varies  somewhat  according 
to  the  region  affected  and  the  cause,  thus  acute  pelvic  peritonitis 
caused  by  the  gonococcus  is  usually  treated  symptomatically  until 
quiescent,  while  locaHzed  peritonitis  the  result  of  appendicitis 
requires  early  operation.  It  should  not  be  forgotten,  however,  that  a 
diffuse  peritonitis  always  begins  as  a  more  or  less  localized  process, 
and  that  in  many  instances  prompt  and  efficient  treatment  of  the 
infection  while  still  limited  may  prevent  its  generalization. 

2.  Acute  diffuse  or  generalized  peritonitis  is  usually  the  result  of 
an  extension  of  a  localized  peritonitis,  although  a  large  area  of  the 
peritoneum  may  be  flooded  wath  infective  material  from  the  bursting 
of  a  localized  abscess,  or  the  perforation  of  a  hollow  viscus.  The 
peritoneum  is  congested  and  lusterless  and  in  fulgurant  cases  death 
may  occur  from  toxemia  before  further  changes  take  place.  As  a 
rule,  however,  there  is  some  serous  exudation,  and  fibrinous  patches 
form  on  the  area  from  which  the  endothelium  has  been  shed.  At  a 
later  period  the  exudate  becomes  purulent  and  occasionally  bloody. 

The  symptoms  at  the  onset  are  those  of  localized  peritonitis,  or 
when  a  large  amount  of  infective  material  has  been  suddenly  dift'used, 
as  in  perforation,  there  will  be  sudden  violent  pain,  profound  shock, 
and  in  some  cases  death  within  a  few  hours.  The  patient  usually 
survives  the  shock,  however,  and  the  temperature  ascends  to  and 
then  above  normal,  and  finally  falls  to  subnormal  as  death  ap- 
proaches, but  the  pulse  remains  quick,  and  becomes  hard  and  wiry 
owing  to  the  rise  in  blood  pressure,  though  in  the  final  stages  it  is 
running  and  compressible.  Chills  are  uncommon  except  in  puerperal 
cases.  Vomiting  is  early  and  persistent,  and  in  the  final  stages 
stercoraceous  material  is  regurgitated  without  effort.  Hiccough  is 
not  infrequent,  and  is  particularly  distressing  because  of  the  increased 


68o  MANUAL    OF    SURGERY 

pain  produced  by  the  spasmodic  contraction  of  the  diaphragm. 
There  is  usually  obstinate  constipation,  occasionally  diarrhea. 
The  patient  lies  on  the  back  with  the  knees  drawn  up,  and  the  face 
has  a  characteristic  anxious  and  pinched  look.  The  abdomen  is 
tender,  rigid,  motionless,  the  breathing  being  quick,  shallow,  and 
entirely  thoracic.  Later  the  abdomen  becomes  tensely  distended 
and  tympanitic,  with  an  amelioration  in  the  pain.  Percussion  may 
show  movable  dulness  in  the  flanks  when  the  effusion  is  great,  or 
absence  of  Hver  dulness  in  perforative  peritonitis.  Air  in  the  peri- 
toneal cavity  may  be  demonstrated  also  by  the  X-rays.  On  auscul- 
tation peristaltic  gurgling  is  absent,  and  occasionally  friction  sounds 
can  be  heard,  more  often  in  the  upper  abdomen,  where,  owing  to  the 
action  of  the  diaphragm,  the  viscera  cannot  be  kept  entirely  at  rest. 
Vaginal  and  rectal  examination  may  reveal  tenderness  and  sometimes 
an  inflammatory  mass.  Leukocytosis  is  present  unless  the  infection 
is  overwhelming.  The  urine  is  scanty,  often  contains  albumin  and 
indican,  and  sometimes  tube  casts  (toxic  nephritis).  For  the  condi- 
tions simulating  peritonitis  but  not  requiring  operation  the  student 
is  referred  to  the  section  on  "Unnecessary  Abdominal  Section." 
Here  we  may  note  the  diflticulty  often  encountered  in  differentiating 
peritonitis  from  intestinal  obstruction,  and  from  intestinal  paralysis 
(q.v.)  due  to  causes  other  than  inflammation  of  the  peritoneum. 
Local  peritonitis,  too,  is  often  confused  with  generahzed  peritonitis. 

Treatment  of  a  prophylactic  nature  includes  operation  for  chronic 
infections  that  may  become  acute  and  spread,  e.g.,  chronic  appendi- 
citis; for  abscesses  that  may  rupture  into  the  peritoneal  cavity;  for 
lesions  that  may  perforate,  e.g.,  duodenal  ulcer,  and  for  abdominal 
injuries  that  may  be  followed  by  peritonitis. 

Medical  treatment  in  acute  peritonitis  is  indicated  when  operation 
is  inadvisable.  Ochsners  method  consists  in  gastric  lavage,  and  no 
food,  water,  or  purgatives  by  mouth.  Purgation  makes  the  feces 
more  liquid,  hence  more  apt  to  leak  through  a  perforation,  and  in- 
creases peristalsis,  which  disseminates  the  infection.  The  lower 
bowel  may  be  emptied  with  an  enema,  water  administered  by  rectum 
as  described  below,  and  the  patient  put  in  the  Fowler  position. 
Poultices  or  ice  bags  on  the  abdomen  are  comforting,  but  have  no 
influence  on  the  disease.  Morphine  lessens  the  pain  and  quiets 
peristalsis,  hence  may  hinder  diffusion  of  the  inflammation,  but, 
since  it  obscures  the  symptoms,  it  should,  if  possible,  be  withheld 
until  a  positive  diagnosis  is  made.  Tympanites  may  be  treated  as 
described  under  "After  Treatment"  in  chap.  iv. 

In  considering  operation  for  acute  generalized    peritonitis  the 


ABDOMEN  68 1 

disease  may  be  divided  into  three  stages.  In  the  first,  or  the  stage 
of  contamination,  which  hists  from  12  to  24  hours,  laparotomy 
should  be  performed  in  all  cases,  excepting  puerperal  peritonitis 
and  that  form  following  salpingitis.  Operation  in  this  stage  might, 
with  propriety,  be  included  among  the  prophylactic  measures. 
In  the  stage  of  established  infection  or  suppuration,  i.e.,  during  the 
second  and  third  days,  and  sometimes  for  a  longer  period,  the  chances 
for  recovery  are,  generally  speaking,  as  good  without  as  with  opera- 
tion. It  is  necessary,  however,  to  study  the  individual  case  before 
coming  to  a  decision,  which  is  rendered  much  easier  if  the  source  of 
the  infection  can  be  diagnosticated.  Thus  in  some  instances, 
notably  acute  perforation,  and  peritonitis  due  to  gangrene  or  stran- 
gulation of  the  intestine,  death  is  almost  certain  if  the  condition  be 
left  unmolested,  while  operation  offers  a  slight  prospect  for  recovery. 
Unfortunately  it  is  often  impossible  to  determine  the  cause  of  the 
peritonitis  before  opening  the  abdomen,  and  in  these  cases  one  may 
operate  with  the  hope  of  finding  a  condition  whose  removal  will 
benefit  the  patient.  In  the  third  stage  the  process  is  subsiding 
and  localizing,  and  operation  should  be  posponed  until  the  maximum 
improvement  has  been  obtained. 

The  most  important  principles  involved  in  any  operation  for 
peritonitis  are  rapidity  and  gentleness.  Unless  the  starting  point  of 
the  inflammation  can  be  localized,  the  incision  should  be  made  in  the 
middle  line  below  the  umbilicus,  and  the  cause  of  the  peritonitis, 
e.g.,  a  gangrenous  appendix,  surrounded  with  gauze  and  quickly 
removed.  The  gauze  packing  prevents  further  dissemination  of  the 
infection  and  absorbs  a  large  quantity  of  the  peritoneal  exudate. 
Drainage  may  sometimes  be  avoided  in  early  operations  (see 
"Penetrating  Wounds  of  the  Abdomen"),  but  should  always  be  empl- 
oyed when  there  is  suppuration.  All  that  is  usually  necessary  is  to 
pass  a  gauze  drain  down  to  the  site  of  the  original  focus  of  infection. 
In  some  cases,  however,  an  additional  drain  may  be  placed  in  the 
lowest  portion  of  the  pelvis  (gaining  exit,  in  the  female,  through  the 
vagina).  Irrigation  of  the  abdomen  increases  the  shock  and  may 
disseminate  the  infection.  Rubber  tubes  in  the  free  peritoneal 
cavity  likewise  are  contraindicated,  as  already  explained  under 
"Surgical  Technic."  After  the  gauze  pack  has  been  removed,  the 
wound  is  sutured,  except  at  the  point  where  the  drain  emerges,  and 
covered  with  a  sterile  dressing.  The  patient  may  then  be  put  in  the 
semi-sitting  posture,  or  the  head  of  the  bed  raised  two  or  three  feet 
(Fowler's  position),  in  order  to  drain  the  fluids  into  the  pelvis  and 
away  from  the  diaphragm,  in  which  region  absorption  is  said  to  be 


682  MANUAL    OF    SURGERY 

most  active.  In  the  gravely  ill,  however,  the  depressing  effects  of  the 
upright  posture  upon  the  heart  far  outweigh  the  theoretical  advan- 
tages just  mentioned.  The  writer  prefers  to  place  the  patient  in  the 
Sims  position,  i.e.,  almost  on  the  abdomen,  on  the  right  side  if  the 
incision  is  right-sided  or  median,  on  the  left  side  if  the  incision  is  on 
the  left  side.  Water  should  be  given  by  bowel,  eight  ounces  every 
three  hours,  or  by  continuous  proctolysis  {Murphy  method),  i.e.,  by 
means  of  a  fountain  syringe,  the  reservoir  of  which,  surrounded  by 
hot  water  bags,  is  but  shghtly  higher  than  the  rectum,  so  that  the 
water  shall  enter  no  faster  than  absorption  takes  place,  the 
patient  getting  perhaps  a  pint  or  two  in  the  course  of  an  hour 
(see  "  Enteroclysis ")  •  This  stimulates  the  heart  and  kidneys, 
eliminates  septic  material  which  has  entered  the  circulation,  and 
reverses  the  current  in  the  lymphatics  of  the  peritoneum,  making 
that  membrane  a  secreting  instead  of  an  absorbing  one.  Occa- 
sionally proctolysis  seems  to  increase  the  distention  and  provoke 
vomiting,  in  which  event  salt  solution  may  be  given  intravenously 
or  subcutaneously.  Nothing  is  given  by  mouth  until  the  stomach  is 
retentive,  stimulants  are  freely  administered,  and  an  early  movement 
of  the  bowels  is  secured  by  means  of  enemata.  When  there  is  great 
distention  which  cannot  be  relieved  by  the  usual  remedies  for  tym- 
panities,  an  artificial  anus  may  be  established.  The  prognosis  will 
depend  upon  the  character,  duration,  and  extent  of  the  infection, 
and  the  resistance  of  the  individual.  Including  all  forms,  irrespec- 
tive of  the  cause,  the  mortality  is  from  15  to  20  per  cent,  in  cases 
which  are  in  fair  condition  at  the  time  of  operation,  and  50  per  cent, 
or  more  in  those  in  bad  condition. 

Chronic  peritonitis  may  be  (i)  simple  or  (2)  tuberculous. 

1.  Simple  chronic  peritonitis  may  be  localized  or  diffuse.  It 
generally  follows  the  acute  form,  but  may  in  mild  infections  be 
chronic  from  the  start.  The  peritoneum  is  thickened,  and  the  adja- 
cent surfaces  fastened  together  by  more  or  less  firm  adhesions.  Sac- 
culated effusions  are  sometimes  encountered.  Syphilis  is  said  to  be 
responsible  for  some  cases.  The  treatment  is  directed  to  the  cause. 
Adhesions  may  be  separated  if  they  give  rise  to  symptoms,  e.g.,  pain 
or  obstruction. 

2.  Tuberculous  peritonitis  may  be  primary,  but  is  usually  second- 
ary to  disease  in  a  distant  organ,  or  to  tuberculosis  of  some  other 
abdominal  structure,  particularly  the  lymph  glands,  the  intestine, 
or  the  Fallopian  tubes.  It  is  more  common  in  females,  and  is  rarely 
seen  before  the  third  or  after  the  fiftieth  year.  Three  forms  are 
described :  (a)  the  ascitic  form  presents  itself  as  a  free  or  sacculated 


ABDOMEN  683 

serous,  sero-fibrinous,  or  occasionally  purulent  exudate,  as  the  result 
of  a  diffuse  miliary  invasion  of  the  peritoneum;  it  is  sometimes  com- 
plicated by  cirrhosis  of  the  liver,  and  it  may  eventuate  in  the  adhe- 
sive form,  (b)  The  fibrous  or  adhesive  variety  is  characterized  by  a 
slow  course  and  the  absence  of  fluid.  The  abdominal  organs  are 
glued  together,  and  gray  or  yellow  tubercles  are  found  among  the 
adhesions.  Not  unusually  the  omentum  is  rolled  upon  itself  and 
is  palpable  as  a  transverse  mass  in  the  upper  part  of  the  abdomen. 
(c)  The  caseous  or  suppurative  form  is  a  later  stage  of  the  adhesive 
variety.  The  tubercles  caseate  and  give  rise  to  abscesses,  which 
may  point  externally,  especially  at  the  navel,  and  lead  to  fecal  fistula), 
the  bowel  often  being  opened  by  ulceration. 

The  local  S5nnptoms  may  arise  suddenly  and  resemble  those  of 
acute  appendicitis  or  other  acute  intraabdominal  conditions,  or  the 
general  symptoms  may  predominate  and  typhoid  fever  be  simulated. 
]\Iost  of  the  cases,  however,  are  chronic.  Pain  and  tenderness  are 
rarely  severe  and  may  be  entirely  absent.  Dysuria  is  not  uncommon, 
particularly  in  women.  The  digestion  is  disturbed,  although  vomit- 
ing is  rare,  and  diarrhea  is  absent  unless  there  is  disease  in  the  intes- 
tine. The  temperature  rises  one  or  two  degrees  in  the  evening,  night 
sweats  may  occur,  and  there  is  a  gradual  loss  of  weight.  The  subcu- 
taneous abdominal  veins  are  generally  distended,  and  free  or  encapsu- 
lated fluid  may  be  detected  in  the  peritoneal  cavity  and  not  infre- 
quently in  a  patent  processus  vaginalis  or  canal  of  Xuck.  The  rolled 
up  omentum  can  be  felt  and  sometimes  seen.  Masses  of  adherent 
intestine  or  enlarged  lymph  glands  may  be  found  on  external,  vagi- 
nal, or  rectal  palpation.  Symptoms  of  stenosis  of  the  intestine  may 
be  present,  the  liver  and  spleen  are  often  enlarged,  and  tuberculosis 
may  be  detected  in  distant  parts  of  the  body. 

The  treatment  may  be  medical  or  surgical.  Medical  treatment 
includes  the  general  measures  employed  for  tuberculosis  elsewhere 
and  local  applications  of  green  soap,  mercurial  ointment,  iodin,  elastic 
collodion,  or  guaiacol.  The  X-ray  and  intraperitoneal  injections  of 
a  weak  solution  of  iodin  also  have  been  used.  Surgical  treatment 
is  of  the  greatest  value  in  the  ascitic  form,  in  which  laparotomy  is 
followed  by  at  least  50  per  cent,  of  permanent  cures.  All  that  is 
needed  is  to  open  the  abdomen,  evacuate  the  fluid,  and  close  without 
drainage.  If  the  cause  of  the  disease,  e.g.,  a  tuberculous  appendix 
or  Fallopian  tube,  is  discovered,  this  may  be  removed.  Separation 
of  adhesions  is  not  infrequently  followed  by  fecal  tistulae.  The  reason 
for  the  beneficial  effect  of  a  simple  laparotomy  is  not  known.  It 
has  been  supposed  that  the  operation  causes  hyperemia,  and  the 


684 


MANUAL    OF    SURGERY 


F.L. 


L.L 


C.oy/dB.L. 


outpouring  of  an  antitoxic  serum.     If  fluid  recollects,  it  may  be 
aspirated  or  a  second  laparotomy  performed. 

Malignant  disease  of  the  peritoneum  may  be  primary  (endothe- 
lioma), but  is  usually  the  result  of  secondary  deposits  from  a  papil- 
liferous  cyst  of  the  ovary  or  a  carcinoma  of  the  ovary,  stomach,  liver 
or  intestine,  the  cancer  cells  having  been  diffused  by  the  peritoneal 
currents  and  the  movements  of  the  viscera.  The  symptoms  are 
those  of  cachexia  and  ascites.  The  fluid  withdrawn  by  tapping  is 
often  blood  stained  and  sometimes  contains  the  tumor  cells.  Multi- 
ple nodules  can  be  felt  through  the  abdominal  wall  and  by  rectum 
and  vaginae. 

Paracentesis  abdominis  is  performed  for  the  removal  of  fluid  from 

the  peritoneal  cavity.  The  bladder 
should  be  emptied,  and  a  spot  of 
absolute  dulness  selected  in  the 
median  line  below  the  umbilicus. 
The  patient  sits  up,  and  a  broad 
flannel  binder  with  an  opening  in 
front  is  passed  around  the  abdomen 
and  held  by  an  assistant  behind,  so 
as  to  make  pressure  upon  the  abdo- 
men. The  skin  is  then  sterilized,  a 
small  incision  made  in  the  skin  with 
a  scalpel,  the  trocar  and  cannula  in- 
serted, and  the  trocar  withdrawn. 

Subphrenic  abscess  is  an  abscess 
just  beneath  the  diaphragm.  About 
one-third  of  the  cases  are  due  to  rup- 

(6)  Right  and  (7)  left  retroperitoneal   tured  gastric  or  duodenal  ulcer,  one- 
spaces.  T    •    • 

fourth  to  appendicitis,  one-nfth  to 
infections  of  the  liver  and  biliary  ducts,  and  the  remainder  to  per- 
foration of  the  intestine,  trauma,  pyemia,  and  suppurative  processes 
in  the  female  generative  organs,  spleen,  pancreas,  kidney,  ribs,  verte- 
bras, or  pleura,  hence  the  abscess  may  be  (a)  intraperitoneal  or  (b) 
retroperitoneal,  (a)  In  the  intraperitoneal  variety  (83  per  cent,  of 
890  cases  collected  by  Piquand)  the  infection  is  transmitted  from 
the  primary  focus  by  the  intraperitoneal  lymph  stream,  which  flows 
towards  the  diaphragm,  or  by  a  spreading  peritonitis.  Its  situation 
depends  upon  the  location  of  the  causative  lesion  and  the  arrange- 
ment of  the  subphrenic  peritoneal  fossae,  which  are  five  in  number, 
four  phrenohepatic,  formed  by  the  cruciform  reflection  of  the  peri- 
toneum from  the  liver  to  the   diaphragm,    and  one  phrenosplenic 


Fig.  374. — Diagram  showing  the 
various  locations  of  subphrenic  abscess. 
Liver  and  spleen  shaded.  Peritoneal 
reflection  to  diaphragm  in  red.  V . 
Vena  cava.  A .  Aorta.  F.L.  Falciform 
ligament.  L.L.  Left  lateral  ligament. 
C.  and  R.  L.  coronary  and  right  lateral 
ligament,  (i)  Right  anterior,  (2) 
right  posterior,  (3)  left  anterior,  and 

(4)  left  posterior  phrenohepatic  spaces. 

(5)  Phrenosplenic  or  perisplenic  space. 


ABDOMEN  685 

(Fig.  374).  (i)  Right  anlcrior  plirciio/ic/xilic  abscess  is  the  most  fre- 
quent (36  per  cent.) ;  it  lies  between  the  right  lobe  of  the  liver  and 
the  diaphragm,  to  the  right  of  the  falciform  ligament,  and  in  front 
of  the  coronary  and  right  lateral  ligaments.  (2)  The  right  posterior 
form  (10  per  cent.)  is  behind  the  coronary  ligament,  extends  down 
towards  the  right  kidney,  and  is  often  associated  with  the  right 
anterior  form.  (3)  Left  anterior  abscess  (30  per  cent.)  presents  in  the 
epigastrium,  adhesions  limiting  it  below.  (4)  A  left  posterior  coWection 
(3  per  cent.)  distends  the  lesser  peritoneal  cavity,  consequently  is 
behind  the  stomach.  (5)  Phrenosplenic  or  perisplenic  abscess  (4  per 
cent.)  occupies  the  space  above  and  about  the  spleen,  (b)  In  retroperi- 
toneal abscess  the  infection  travels  by  way  of  the  lymph  vessels  or 
by  a  spreading  cellulitis,  (i)  Right  retroperitoneal  abscess  (15  per 
cent.)  may  extend  forwards  between  the  layers  of  the  coronary  and 
falciform  ligaments  and  point  in  the  epigastrium,  or  downwards 
and  point  in  the  right  loin;  (2)  left  retroperitoneal  (2  per  cent.)  forwards 
between  the  layers  of  the  left  lateral  ligament  and  downwards  to  the 
left  loin.  A  subphrenic  abscess  often  contains  gas,  owing  to  the 
presence  of  the  colon  bacillus,  or  to  perforation  of  the  gastro- 
intestinal canal  or  lung.  It  may  cause  empyema,  rarely  pyoperi- 
cardium,  by  breaking  into  the  pleural  cavity  or  pericardium,  or  by 
extension  of  the  infection  along  the  lymphatics  through  the  diaphragm 
without  perforation.  It  may  break  also  into  the  lung,  the  general 
peritoneal  cavity,  the  stomach,  the  intestine,  the  mediastinum,  or 
in  rare  instances  externally  (hypochondrium,  epigastrium,  loin). 

The  symptoms  are  usually  preceded  or  accompanied  by  those  of 
the  causative  lesion.  The  general  phenomena  are  those  of  sepsis. 
Locally  there  are  pain  and  tenderness,  muscular  rigidity,  perhaps 
swelling  and  edema,  and,  on  percussion,  a  tympanitic  area  which 
moves  with  the  position  of  the  patient,  or  dulness.  Friction  sounds 
are  occasionally  heard  and  when  the  abscess  contains  gas  all  the 
signs  of  pneumothorax  may  be  present,  hence  the  term  false  pneumo- 
thorax. Fluoroscopic  examination  reveals  elevation  and  possibly  im- 
mobility of  the  diaphragm  on  the  affected  side,  below  which  (patient  in 
erect  position)  is  a  clear  area  if  the  abscess  contains  gas.  The  liver  or 
the  spleen  is  depressed.  Explorator}-  aspiration  may  be  made  in  the 
tenth,  ninth,  eighth,  and  seventh  interspaces,  in  the  order,  named, 
first,  below  the  scapula,  and  then,  if  no  pus  is  found,  in  the  midaxillary 
line,  but  never  through  the  peritoneum,  and  only  when  all  prepara- 
tions have  been  made  for  immedite  operation  in  case  the  abscess  is 
located.  The  diagnosis  of  subphrenic  abscess  is  often  difficult, 
and  the  conditions  which  it  resembles  are  often  associated  with  it. 


686  MANUAL    OF    SURGERY 

In  hepatic  abscess  there  may  be  jaundice  and  gas  is  never  present. 
Pancreatitis  may  reveal  itself  fey  the  laboratory  tests  for  this  condi- 
tion. In  empyema  the  pulmonary  symptoms  are  more  marked,  the 
upper  level  of  the  fluid  is  concave  instead  of  convex,  the  heart  is 
pushed  to  one  side  rather  than  upwards,  the  liver  is  not  depressed, 
the  obliquity  of  the  ribs  is  increased  (being  decreased  in  subphrenic 
abscess),  the  level  of  the  diaphragm  as  shown  by  the  X-ray  is  not 
disturbed,  the  Litten  phenomenon  (visibility  of  the  excursions  of  the 
diaphragm  in  the  intercostal  spaces)  is  absent,  and  Traube's  space 
is  rarely  obliterated,  a  sign  which  may  occur  in  left  subphrenic  ab- 
scess. Bronchial  breathing,  owing  to  compression  of  the  lung,  is 
sometimes  heard  in  subphrenic  abscess,  but  never  egophony.  In 
empyema,  on  exploratory  puncture,  the  pus  is  more  superficial, 
escapes  under  greater  pressure  during  expiration  (the  reverse  being 
true  in  subphrenic  abscess),  and  the  needle  does  not  oscillate.  When 
the  needle  passes  through  the  diaphragm  its  outer  end  ascends  on 
inspiration,  descends  on  expiration.  When  a  serous  pleural  effu- 
sion and  a  subphrenic  abscess  are  both  present,  one  may  obtain 
serous  fluid  superficially  and  fetid  pus  at  a  deeper  level,  or  serum  in 
the  sixth  or  seventh  interspace  and  pus  in  the  ninth  or  tenth.  The 
mortality  of  subphrenic  abscess  is  almost  loo  per  cent,  without  opera- 
tion, 50  per  cent,  with  operation. 

.  The  treatment  is  evacuation.  According  to  the  situation  of  the 
abscess,  the  incision  will  be  made  in  the  epigastrium,  the  hypochon- 
drium,  the  loin,  or  through  the  diaphragm  after  resecting  the  ninth 
or  tenth  rib  and  pushing  the  pleura  upwards  (subpleural  route),  or 
sewing  the  diaphragm  to  the  parietal  pleura  (transpleural  route). 

The  omentum  has  been  called  "the  policeman  of  the  abdomen," 
because  of  its  tendency  to  adhere  to  and  surround  diseased  processes 
and  prevent  their  diffusion;  it,  therefore,  participates  in  diseases 
common  to  the  peritoneum. 

Volvulus  of  the  omentum  in  most  instances  is  caused  by  forcible 
taxis  of  an  epiplocele,  although  it  may  occur  without  the  presence  of 
a  hernia.  The  omentum  becomes  gangrenous,  and  the  patient  is 
usually  operated  upon  with  the  idea  that  he  has  a  strangulated 
hernia  or  appendicitis.  A  doughy  abdominal  tumor  coming  on 
after  attempts  to  reduce  a  hernia  should  make  one  suspicious  of  an 
omental  torsion.     The  involved  portion  should  be  excised. 

Timiors  of  the  omentimi  and  mesentery  are  uncommon,  and  are 
generally  sarcomatous  in  nature,  although  benign  growths  and 
secondary  carcinoma  may  occur.  Free  fatty  tumors  in  the  peritoneal 
cavity  represent  lipomata  of  the  omentum  or  epiploic  appendages, 


ABDOMEN  687 

the  pedicle  of  which  has  broken.  The  rolled  up  tuberculous  omen- 
tum has  already  been  described.  Cysts  of  the  omentum  and  mesen- 
tery also  are  rare,  and  are  frequently  caused  by  the  echinococcus 
or  by  cystic  degeneration  of  malignant  disease.  In  the  mesentery 
serous,  sanguineous,  chylous  (Fig.  375),  and  dermoid  cysts  have  been 
observed.  These  tumors  and  cysts  are  freely  movable,  surrounded 
by  tympany  on  all  sides,  and  are  not  connected  with  the  pelvis. 
The  treatment  is  extirpation,  an  operation  that  may  necessitate 
intestinal  resection.  When  the  extirpation  of  a  cyst  is  impossible 
it  may  be  opened  and  stitched  to  the  abdominal  wall. 

Retroperitoneal  tumors,  excluding  those  of  the  kidney  and  the 
pancreas,  are  usually  sarcomata,  lipomata,  or  dermoids.  Tabulated 
swellings  representing  enlarged  lymph  glands  may  be  due  to  syphilis, 
tuberculosis,  leukemia,  Hodgkin's  disease,  typhoid  fever,  primary 
lymphosarcoma,  or  to  secondary  new 
growths,  either  sarcoma  or  carcinoma. 
Particular  mention  should  be  made  of 
the  metastatic  involvements  of  these 
glands  occurring  in  chloroma,  lympho- 
sarcoma of  the  neck,  and  malignant  dis- 
ease of  the  testicle.  Failure  to  ascertain 
the  nature  of  a  tumor  that  has  been  ex- 
cised from  the  neck,  or  to  note  that  the 
testicle  has  been  removed  or  is  diseased, 
may  lead  to  a  useless  abdominal  opera- 
tion. Chronic  abscesses,  most  fre- 
quently   originating    in    a    tuberculous     Pig- 3  7S-— Cyst  of  mesentery,  prob- 

spondylitis  or  lymphadenitis,   also  are 

observed,  and  the  possibility  of  aneurysm  should  not  be  forgotten. 
The  distinguishing  features  of  a  retroperitoneal  tumor  are  its  im- 
mobihty,  the  presence  of  tympany  in  front  of  it,  and  often  the  ab- 
sence or  paucity  of  symptoms  referable  to  the  intraperitoneal  organs. 
Retroperitoneal  tumors  amenable  to  operation  may  be  extirpated 
from  the  front,  thus  going  through  the  anterior  and  posterior  parietal 
peritoneum.  Abscesses  should  be  drained  extraperitoneally,  by 
an  incision  in  the  loin  or  above  Poupart's  ligament. 

Thrombosis  or  embolism  of  the  mesenteric  vessels  causes  gan- 
grene of  that  portion  of  the  intestine  supplied  by  the  vessel  involved, 
unless  the  vessel  be  small,  when  there  may  be  only  engorgement  of  the 
intestine,  or  ulceration,  followed  perhaps  by  perforation.  In  some 
cases  the  mesentery  is  distended  with  extravasated  blood.  The 
condition  is  rare  in  children,  most  of  the  cases  occurring  between  the 


688  MANUAL    OF    SURGERY 

thirtieth  and  seventieth  years,  men  being  affected  nearly  twice  as 
often  as  women.  Embolism  is  frequently  the  result  of  cardiac  disease, 
and  is  sometimes  associated  w^ith  the  presence  of  emboli  in  other  por- 
tions of  the  body.  Thrombosis  is  caused  by  acute  or  chronic  phle- 
bitis, the  result  of  infection  from  the  intestine  or  other  organ,  or  by 
chronic  endarteritis.  In  Trotter's  collection  of  366  cases,  the  arteries 
wTre  involved  in  53  per  cent.,  the  veins  in  41  per  cent.,  both  in  six 
per  cent.  The  superior  mesenteric  vessels  were  more  often  occluded 
than  the  inferior.  The  diagnosis,  before  operation  or  autopsy,  was 
made  thirteen  times.  The  symptoms  are  sudden  intense  pain, 
bloody  diarrhea  in  half  the  cases,  vomiting,  subnormal  temperature, 
rapid  pulse,  meteorism,  and  abdominal  rigidity.  The  treatment  is 
resection  of  the  gangrenous  intestine,  if  the  process  be  sufficiently 
limited.  If  the  superior  mesenteric  artery  is  occluded  near  its 
origin,  the  entire  small  intestine,  with  the  ascending  and  transverse 
colon,  will  be  gangrenous  and  no  treatment  applicable.  In  Trotter's 
series  36.2  per  cent,  of  those  operated  upon  recovered. 

THE  STOMACH 

Congenital  stenosis  of  the  pylorus  is  due  to  spasm  or  to  what  is 
probably  the  result  of  persistent  spasm,  hypertrophy  of  the  sphincter 
with  fibrous  overgrowth  of  the  submucous  tissues.  The  symptoms 
which  usually  begin  from  a  few  days  to  a  few  weeks  after  birth,  are 
vomiting,  intermittent  if  caused  by  spasm  of  the  pylorus,  persistent, 
regular,  projectile,  and  not  bile  stained  if  the  result  of  complete 
stenosis;  distention  of  the  upper  abdomen,  due  to  dilatation  of  the 
stomach;  retraction  of  the  lower  abdomen,  due  to  collapse  of  the 
bowel;  palpable  pyloric  tumor  in  two-thirds  of  the  cases;  visible  gas- 
tric peristalsis,  passing  from  left  to  right;  emaciation,  progressive  in 
complete  stenosis;  oliguria;  and  constipation,  alternating  with  diarr- 
hea in  pylorospasm,  and  extreme  in  complete  stenosis,  an  additional 
sign  of  which  is  the  failure  of  methylene  blue  to  appear  in  the  stools 
after  being  taken  by  mouth.  X-ray  examination,  after  the  adminis- 
tration of  barium,  shows  the  gastric  dilatation;  in  pylorospasm  the 
bismuth  may  be  retained  in  the  stomach  for  a  variable  period  and 
then  passed  rapidly  into  the  duodenum;  in  complete  stenosis  the  bis- 
muth remains  in  the  stomach  until  vomited. 

The  treatment  of  spasmodic  or  incomplete  stenosis  is  daily  gastric 
lavage;  small  quantities  of  peptonized  milk  or  beef  juice  by  mouth 
supplemented  by  nutrient  enemata  and  cod-liver  oil  inunctions; 
heat  to  the  abdomen;  and  small  doses  of  the  bromides  or  opium  per 


ABDOMEN  689 

rectum.  If  V()niitiii<,f  and  emaciation  continue,  or  if  there  are  signs 
of  complete  occlusion,  the  Rammstcdt  oprriilion  should  be  performed. 
A  short  incision  is  made  through  the  right  rectus  muscle,  the  pylorus 
grasped  between  the  thumb  and  the  index  finger,  and  its  outer  coats 
severed,  from  the  normal  gastric  wall  almost  to  the  duodenum,  in 
the  axis  of  the  pylorus,  over  the  least  vascular  portion  of  the  tumor, 
which  is  usally  the  upper  and  outer  quadrant.  The  mucous  mem- 
brane bulges  into  the  gap,  which  may  be  widened  by  inserting  the 
end  of  a  pair  of  hemostatic  forceps  and  gently  separating  the  blades. 
The  pylorus  may  then  be  dropped  back  into  the  abdomen,  or  the 
gap  may  be  filled  with  fat  or  muscle,  or  covered  with  a  flap  of  peri- 
toneum. As  soon  as  the  eiifects  of  the  anesthetic  have  disappeared, 
the  baby  may  begin  to  nurse  from  the  breast,  at  first  for  brief  periods, 
w^hich  are  gradually  lengthened  until  the  normal  is  reached.  The 
special  dangers  of  the  operation  are  perforation  of  the  mucous  mem- 
brane, particularly  when  the  incision  approaches  the  duodenum; 
hemorrhage,  which  may  prove  fatal  after  operation,  unless  great 
care  is  taken  to  stop  all  bleeding,  even  though  it  may  appear  to  be 
of  a  trivial  nature;  and  breaking  open  of  the  incision  in  the  abdominal 
wallowing  to  s  training  and  crying,  hence  the  stitches  should  be  allowed 
to  remain  for  two  weeks,  and  the  abdomen  supported  with  broad 
bands  of  adhesive  plaster.  The  mortality  of  gastroenterostomy  for 
congenital  pyloric  stenosis  is  about  50  per  cent.,  that  of  the  Ramm- 
stedt  operation  about  25  per  cent.  The  Rammstedt  operation 
necessitates  only  a  short  incision  in  the  abdominal  wall,  and  can  be 
performed  much  quicker  than  gastroenterostomy,  both  of  which 
features  are  of  considerable  importance  when  dealing  with  an  infant. 
Rupture  of  the  stomach  (see  "Contusions  of  the  Abdomen")- 
Foreign  bodies  which  are  swallowed  may  give  no  trouble,  and 
finally  be  expelled  through  the  anus.  Balls  of  hair,  etc.,  which  have 
formed  as  the  result  of  the  habit  of  swallowing  small  particles  of  such 
material,  may  reach  a  great  size  and  be  mistaken  for  a  neoplasm. 
In  these  cases,  or  in  case  a  small  foreign  body  lodges  and  causes 
mischief,  gastrotomy  may  be  performed  and  the  offending  material 
removed.  The  X-ray  will  often  be  of  value  for  diagnostic  purposes. 
Peptic  ulcer  of  the  stomach  is  due  to  auto-digestion  of  the  gastric 
wall  as  the  result  of  excessively  acid  gastric  juice  {hy perchlorhydria) , 
the  resistance  of  the  mucous  membrane  often  being  lowered  by 
anemia,  gastritis  (especially  the  alcoholic  form) ,  sometimes  by  throm- 
bosis, and  occasionally  by  injury.  Ulcers  due  to  syphilis,  tubercu- 
losis, neoplasms,   certain  forms  of  toxemia   (hemorrhagic  erosion), 

the  swallowing  of  corrosives,  etc.,  are  not  included  under  this  heading, 

44 


690  MANUAL    OF    SURGERY 

although  the  symptoms  may  be  identical  with  those  of  peptic  ulcer. 
Ninety  per  cent,  of  the  peptic  ulcers  are  situated  on  the  posterior 
wall  of  the  pyloric  region  near  the  lesser  curvature,  because  it  is 
against  this  point  that  the  gastric  contents  are  hurled,  during  diges- 
tion, by  the  contraction  of  the  greater  curvature.  Two  forms  are 
described,  the  acute  and  the  chronic. 

Acute  ulcer  is  round,  smooth,  and  funnel-shaped,  with  the  base 
towards  the  cavity  of  the  stomach.  The  edges  are  sharply  defined, 
have  little  or  no  induration,  and  healing  takes  place  with  scarcely 
any  contraction.  Acute  ulcer  is  most  frequent  in  chlorotic  females 
between  the  fifteenth  and  the  thirtieth  year.  It  is  generally  single, 
but  sometimes  there  are  multiple  ulcers,  which  may  involve  not 
only  the  stomach,  but  also  the  duodenum  and  the  lower  end  of  the 
esophagus. 

Chronic  ulcers  are  usually  solitary  (95  per  cent.),  have  indurated 
edges,  and  may  be  large  and  irregular.  They  produce  great  con- 
traction when  they  heal,  are  often  adherent  to  adjacent  viscera, 
and  usually  ocur  in  males  (75  per  cent,  of  the  cases)  between  the 
ages  of  thirty  and  fifty.  According  to  Mayo  two-thirds  of  all  ulcers 
of  the  stomach  and  duodenum  are  duodenal.  Duodenal  ulcer  is 
discussed  in  the  section  on  "The  Intestines." 

Symptoms  may  be  entirely  absent  {latent  ulcer).  In  a  typical 
case  there  is,  in  addition  to  the  symptoms  to  be  noted  below,  indiges- 
tion, i.e.,  flatulence,  acid  eructations  (heart  burn),  and  a  sensation 
of  fullness,  heaviness,  burning,  or  uneasiness  in  the  epigastrium. 
Although  almost  all  patients  with  gastric  ulcer  have  indigestion, 
in  most  cases  of  indigestion  the  cause  is  not  in  the  stomach,  and  in 
many  cases  not  even  in  the  abdomen.  The  pain  of  gastric  ulcer  is 
dull  and  gnawing,  occasionally  sharp.  It  occurs  in  the  region  of  the 
ulcer,  often  passes  through  to  the  back,  and  is  sometimes  felt  beneath 
the  sternum,  around  the  heart,  in  the  neck  over  the  corresponding 
vagus,  or  in  the  larynx.  It  is  relieved  by  sodium  bicarbonate  and 
vomiting.  If  the  pain  is  continuous,  or  does  not  cease  after  vomit- 
ing, it  is  generally  not  due  to  ulcer,  unless  the  ulcer  has  reached  the 
peritoneum  or  become  malignant.  The  time  the  pain  occurs  depends 
upon  the  situation  of  the  ulcer.  In  ulcers  to  the  left  of  the  median 
line  pain  may  be  experienced  as  soon  as  food  enters  the  stomach; 
in  pyloric  ulcer  pain  may  not  occur  for  one,  two,  or  three  hours  after 
meals.  When  pain  is  deferred  until  near  the  next  meal  and  is 
relieved  by  eating  (hunger  pain)  the  ulcer  is  usually  in  the  duodenum. 
Pain  after  eating  is  due  to  peristalsis,  gaseous  distension,  physiologic 
congestion,  increase  in  the  HCl,  and  to  direct  irritation  of  the  food. 


ABDOMEN  091 

The  K-iulcriicss,  as  a  rule,  is  sharph'  localized  to  one  point,  the 
situation  of  which  is  governed  by  the  situation  of  the  ulcer  (Fig.  376). 
Rigidity  of  the  epigastric  muscles  is  most  frec^uent  when  the  ulcer 
spread  to  the  peritoneum.  Vomiting  occurs  at  periods  fixed  by  the 
pain.  Tt  may  be  self-induced,  but  is  more  often  involuntary,  being 
caused  by  pylorospasm  in  acute  ulcer  and 
in  the  early  stages  of  chronic  ulcer,  and 
usually  by  mechanical  obstruction  in  late 
cases.  Vomiting  without  pain  or  indiges- 
tion is  rarely  due  to  ulcer.  Bleeding  mani- 
fests itself  by  hematemesis,  visible  or  occult 
blood  in  the  stools,  or  by  the  general  symp- 
toms of  anemia.  Hematemesis  occurs  in 
one-third  of  the  cases,  the  quantity  of  blood 
varying  from  a  few  drops  to  a  pint  or  more. 
In  chronic  cases  a  tumor  may  sometimes      _ 

.        .  ^iG-     376. — Tender    points 

be  felt.      As  a  rule  the  appetite  is  good,  but    in  some  abdominal  affections. 

the  patient  is  afraid  to  eat.     Anorexia  is  Jj  ^'dZ.S^o'Z' iT^iTt.! 

more    frequent    in    carcinoma.      The    symp-    median  line;  pain  may  radiate 
.     ,.      ,,  .  .         '.  '•iP  beneath  the  sternum  and 

toms  recur  periodically,  ottener  in  winter  to  the  heart.  2.  uicer  near 
than  in  summer,  so  that  relapses  after  ap-  the  pylorus.    3.  Duodenal 

,      ,  ,      ulcer.    In  I,  2,  and  3,  pain  may 

parent   cure   are   common.     Emaciation  is  strike  through  to  the  back.    4. 

.,,.,,  .,,  ...  .,       Affections  of  the   gall-bladder 

induced  in  those  cases  With  persistent  vomit-  (Robsons  point);  pain  may 
ing.     Examination  of  the  stomach  contents  radiate  to  epigastrium,  around 

.    ,  the  right  side  of  the  back,  and 

shows  an  excess  of  HCl.     After  administer-  up  to  the  right  shoulder.    5. 

•    _  u       •  iL         1  T    1  1..  Chronic    pancreatitis   (Des- 

ing  barium,  the  ulcer,  it  deep,  may  show  on  .^^^.^,^  p^^P,).  ^^^  ^^^.^^^^ 
a  skiagram  as  a  notch  with  the  base  towards  ^o  the  epigastrium  and  some- 

.  times  to  the  left  shoulder.     6. 

the  stomach,  and  opposite  this  there  may  Appendicitis  (Mc Bur ney's 
be  a  sharp  indentation  of  the  greater  curva-  f"'''*^'.  p^!"  °^*^^  ^l^'""'  l"" 

'^  ^  _  the  epigastrium  or  about  the 

ture,  due  to  spasm.     An  aero-bismuth  diver-  umbilicus.    7.    Diverticulitis. 

.  •       1  .  1-    1  ,      ,     •  •  1  8.   Ovaritis;  pain  may  radiate 

ticulum.  I.e.,  a  light  stain  superimposed  on  down  the  thigh.  9.  Renal 
a    dark    stain,    means    penetration  into  a  foli'^:  P^i"  radiates  from  the 

loin,   along   the  ureter,  to  the 

neighboring  viscus,  usually  the  pancreas  or  genitals.  10.  Direction  of  pain 
the  liver,  hence  may  require  a  profile  picture  guinarhernil'affeSro^he' 
for  its  demonstration.     In  most  instances,  testicle   and  spermatic  cord, 

vesiculitis. 

however,  the  ulcer  does  not  show,  and  the 

X-ray  demonstrates  merely  a  dilatation  of  the  stomach,  due  to  pyloro- 
spasm or  cicatricial  stenosis,  with  a  delay,  often  of  six  hours  or 
more,  in  the  passage  of  the  bismuth  into  the  duodenum.  Reversed 
peristalsis  and  numerous  large  peristaltic  waves,  as  observed  with  the 
liuoroscope,  is  indicative  of  pyloric  stenosis.  Among  the  complica- 
tions and  sequelae  are  perforation  (general  peritonitis,  subphrenic 


692  MANUAL    OF    SURGERY 

abscess,  etc.),  grave  hematemesis,  tetany,  perigastric  adhesions, 
bilocular  stomach,  orifice  (spasmodic  or  cicatricial),  and  carcinoma. 
Because  of  the  deformities  of  the  stomach  they  may  produce  and  the 
possibility  of  malignant  degeneration,  gastric  ulcers  are  generally 
regarded  as  more  serious  than  duodenal  ulcers. 

The  treatment  of  uncomplicated  acute  ulcer  is  medical.  Chronic 
ulcer  should  be  treated  by  gastroenterostomy  if  marked  improvement 
or  recovery  does  not  occur  after  three  months  of  medical  treatment. 
The  mortality  of  chronic  ulcer  treated  medically  is  25  per  cent. 
(Robson),  of  gastroenterostomy  for  this  condition  three  per  cent. 
As  to  the  late  results  about  75  per  cent,  regain  good  health,  10 
per  cent,  are  much  improved,  5  per  cent,  are  slightly  improved,  and 
5  per  cent,  develop  a  recurrence,  a  carcinoma,  or  some  other  compli- 
cation or  sequel.  Moynihan,  in  addition  to  gastroenterostomy, 
inverts  the  ulcer  with  sutures  to  prevent  perforation,  and  ties  all 
visible  vessels  leading  to  the  ulcer  to  prevent  hemorrhage.  Gastro- 
enterostomy drains  the  stomach,  puts  the  ulcer  at  rest,  and,  by  allow- 
ing a  slight  reflux  of  bile  and  pancreatic  juice  through  the  anastomotic 
opening,  partly  neutralizes  the  gastric  acidity.  When  the  pyloro- 
spasm  ceases  food  tends  to  pass  again  through  the  pylorus,  thus  oc- 
casionally leading  to  recurrence  of  the  ulcer.  This  fact,  with  the 
observation  that  the  best  results  are  obtained  when  the  pylorus  is 
stenosed,  has  suggested  that,  whenever  gastroenterostomy  is  per- 
formed the  pylorus,  if  open,  be  closed  artificially  (see  "Exclusion  of 
the  Pylorus").  Excision  of  the  ulcer,  followed  by  gastroentero- 
stomy, is  recommended  by  a  few  surgeons  for  all  cases,  but  as  the 
operation  is  more  difficult  and  dangerous  (mortality  10  per  cent.) 
than  gastroenterostomy  alone,  it  should  be  practised  only  when  the 
induration  be  such  as  to  give  rise  to  a  suspicion  of  cancer,  when  the 
the  ulcer  is  so  situated,  e.g.,  at  a  distance  from  the  pylorus,  as  to  be 
little  influenced  by  gastroenterostomy,  or  when  the  ulcer  has  given 
rise  to  repeated  hemorrhages.  The  differentiation  at  operation 
between  ulcer  and  carcinoma  is  often  difiicult.  The  clinical  history 
and  the  results  of  the  laboratory  tests,  including  the  X-ray  examina- 
tion, should  be  taken  into  consideration.  In  ulcer  there  is  more 
apt  to  be  edema  and  extensive  inflammatory  adhesions,  and  there 
are  no  carcinomatous  foci  in  the  neighborhood.  Enlarged  glands 
may  be  found  in  both  ulcer  and  carcinoma.  In  some  cases  a  frozen 
section  may  be  made  to  decide  the  question.  Excision  gets  rid  of 
the  ulcer,  but  unfortunately  not  of  the  cause  of  the  ulcer,  hence 
does  not  exclude,  as  some  believe,  the  possibility  of  recurrence  and 
carcinoma.     For  the  methods  of  excision  see  "Partial  Gastrectomy." 


ABDOMEN  ■  693 

If,  at  operation,  no  ulcer  can  be  demonstrated  a  gastroenterostomy 
should  not  be  performed  on  the  theory  that  it  will  do  no  harm,  be- 
cause if  it  is  not  indicated,  it  may  do  harm,  especially  in  the  neu- 
rotic. The  inexperienced  ma\'  easily  be  deceived  by  the  localized 
muscular  contraction  of  the  gastric  wall  that  follows  pinching; 
this  hard  area,  if  watched  for  a  short  time,  can  be  seen  to  relax. 
When  no  ulcer  is  present  the  other  abdominal  organs  should  be 
reviewed  and  any  lesion  in  them  corrected.  The  appendix  should  be 
mentioned  particularly,  as  it  not  infrequently  produces  symptoms 
closely  resembling  those  of  gastric  ulcer  {appendicular  dyspepsia). 

Perforation  of  the  ulcer  occurs  in  about  10  per  cent,  of  the  cases, 
and  is  much  more  frequent  on  the  anterior  than  the  posterior  wall, 
owing  to  the  formation  of  protecting  adhesions  to  the  pancreas  in  the 
latter  situation.  The  symptoms  vary  in  intensity  according  to 
whether  the  perforation  is  actite  (no  adhesions,  wide  diffusion  of 
stomach  contents  through  peritoneal  cavity),  subacute  (minute 
opening  and  gradual  leakage),  or  chronic  (protecting  adhesions  and 
localized  peritonitis).  Acute  perforation  is  announced  by  sudden 
violent  pain  in  the  epigastrium,  which  often  radiates  to  the  back,  up 
to  the  left  shoulder,  and  down  into  the  right  iliac  fossa.  There  are 
great  tenderness,  marked  rigidity  of  the  abdominal  muscles,  and 
shock  of  varying  severity.  Pneumoperitoneum  may  be  shown  by 
absence  of  the  liver  dulness  and  by  the  X-ray.  Movable  dulness  in 
the  flanks  is  unusual  unless  the  quantity  of  gastric  contents  extra- 
vasated  is  very  large.  In  about  half  the  cases  the  stomach  contents 
are  vomited,  but  rarely  is  there  any  blood.  In  10  per  cent,  of  the 
cases  there  is  no  previous  history  of  indigestion.  There  may  be  a 
leukocytosis. 

The  treatment  is  immediate  abdominal  section,  any  existing 
shock  being  combated  while  the  preparations  for  operation  are  under 
way.  The  incision  is  made  through  the  right  rectus  muscle  above 
the  umbilicus,  and  the  perforation  closed  by  a  double  row  of  Lem- 
bert's  sutures  of  silk  without  excising  the  ulcer.  In  cases  in  which 
owing  to  the  friability  of  the  tissues,  or  the  size  or  situation  of  the 
perforation,  suture  is  impossible,  the  opening  may  be  closed  with 
omentum,  gauze  packing,  or  by  covering  it  wdth  the  adjacent  portion 
of  the  duodenum.  The  possibility  of  a  second  perforation  should 
never  be  forgotten.  Gastroenterostomy  should  be  performed  if 
there  is  much  stenosis  of  the  pylorus.  In  other  cases  it  may  be 
performed,  if  the  patient  is  in  good  condition.  Drainage  is  generally 
unnecessary  in  early  cases  in  which  the  perforation  has  been  securely 
closed.     It  should  be  employed  in  late  operations,  i.e.,  after  the  first 


694  MANUAL    OF    SURGERY 

12  or  18  hours,  when  the  exudate  is  purulent,  when  a  large  quantit 
of  food  has  escaped  into  the  peritoneal  cavity,  and  when  the  perfora- 
tion cannot  be  closed  satisfactorily.  In  these  cases  a  gauze  drain 
may  be  placed  in  the  vicinity  of,  but  not  in  contact  with  the  sutured 
perforation,  and  a  second  incision  made  above  the  pubes  for  the 
purpose  of  draining  the  pelvis.  The  mortality  of  early  operation 
is  five  per  cent.,  of  late  operation  50  per  cent. 

Hematemesis,  or  gastrorrhagia,  becomes  a  compHcation  of  ulcer 
of  the  stomach  when  it  is  persistent  or  grave.  It  may  occur  at  any 
time  during  the  progress  of  the  ulceration,  and  is  the  cause  of  death 
in  from  3  to  5  per  cent,  of  all  cases  (Welch).  In  the  acute  form  the 
patient  vomits  a  large  quantity  of  blood,  sometimes  a  quart  or  more, 
and  may  never  have  another  hemorrhage,  or  the  hematemesis 
be  repeated  at  intervals  of  several  days  or  longer.  Death  from  one 
hemorrhage  is  not  common,  but  such  may  take  place,  even 
without  the  vomiting  of  blood,  when  a  large  artery,  like  the  coronary 
or  the  gastroduodenal,  is  opened.  The  chronic  form  consists  in 
repeated  small  hemorrhages.  The  diagnosis  involves  a  differentia- 
tion from  hemoptysis,  and  conditions  like  epistaxis,  in  which  the 
blood  has  been  swallowed  and  subsequently  vomited.  In  hemoptysis 
the  blood  is  frothy,  bright  red,  and  alkalin  instead  of  acid;  it  follows 
coughing,  and  the  physical  signs  of  phthisis  are  present.  An  ex- 
amination of  the  nose  and  throat  will  usually  reveal  a  lesion  if  the 
blood  has  been  swallowed.  Besides  ulcer,  hematemesis  may  be 
caused  by  a  leaking  aneurysm,  rupture  of  varices  of  the  stomach  or 
esophagus  due  to  obstruction  of  the  portal  circulation  (e.g.,  in 
aft'ections  of  the  heart,  spleen,  pancreas,  and  liver,  particularly 
atrophic  cirrhosis),  cancer  of  the  stomach  or  other  tumor,  ingestion  of 
caustics,  '^hemorrhagic  erosion"  (e.g.,  in  uremia,  phthisis,  chronic 
alcoholism,  yellow  fever,  scorbutus,  and  leukemia),  post-operative 
hematemesis,  which  is  supposed  to  be  of  infectious  origin  and  follows 
abdominal  operations,  fieuropathic  hematemesis,  and  vicarious 
menstruation.  For  clinical  purposes  it  may  be  said  that  a  gastric 
hemorrhage  occurring  in  the  apparently  healthy,  or  in  those  who 
complain  of  pain  and  dyspepsia,  is  due  to  an  ulcer. 

The  treatment  of  a  first  attack  of  ac^lte  hemorrhage  is  absolute 
rest,  no  food  by  stomach,  ice  to  the  epigastrium,  and  the  injection  of 
horse  serum  or  the  transfusion  of  blood.  Chlorid  of  calcium  per  rec- 
tum, one  to  two  grams,  adrenalin  by  mouth,  and  the  subcutaneous 
injection  of  gelatin  or  ergotin  also  have  been  recommended.  With 
this  treatment  the  hemorrhage  will  cease  in  93  per  cent,  of  the 
cases,  operation  under  the  same  circumstances  has  a  mortality  of 


ABDOMEN  C95 

37  per  cent.  Should  the  hemorrhage  be  repeated  once,  or  at  most 
twice,  operation  may  be  undertaken,  but  is  often  unsatisfactory, 
as  the  bleeding  point  may  not  be  found,  or,  if  found,  hemostasis  may 
be  difficult  or  impossible.  The  stomach  is  exposed  by  a  median 
incision  and  the  exterior  examined  for  evidences  of  the  ulcer  (adhe- 
sions, scar,  thinning  of  the  coats) ;  if  such  are  absent,  the  stomach  is 
opened,  emptied,  everted,  and  the  mucous  membrane  carefully  exam- 
ined. The  bleeding  point  is  ligated,  sutured  or  cauterized ;  or  the  ulcer 
is  ligated  en  masse  or  excised  (partial  gastrectomy  or  pylorectomy) . 
If  the  bleeding  point  cannot  be  found,  or  if  there  is  general  oozing, 
or  pyloric  stenosis,  a  gastroenterostomy  should  be  performed. 
Chronic  liemorrhage  is  treated  by  gastroenterostomy,  with  infolding 
or,  better,  excision  of  the  ulcer. 

Gastric  tetany  presents  the  same  symptoms  as  other  forms  of 
tetany.  It  is  very  rare  and  almost  always  associated  with  gastrec- 
taisa,  hence  the  treatment  is  that  of  dilatation  of  the  stomach. 

Perigastric  adhesions  may  be  caused  by  ulcer  of  the  stomach  or 
duodenum,  by  trauma,  by  inflammatory  affections  of  the  biliary  appa- 
ratus, pancreas,  spleen,  or  intestine,  and  by  tuberculous  peritonitis. 
The  symptoms  are  those  of  stenosis  of  the  pylorus,  or  indigestion, 
with  pain,  particularly  when  the  organ  is  distended.  X-ray  examina- 
tion may  show  an  abnormal  position  of  the  pylorus,  too  slight  or  no 
displacement  on  different  observations  in  different  postures,  or 
deformity  of  the  pylorus  or  the  stomach.  The  adhesions  may  be 
separated  [gastrolysis) ,  and  the  raw  surfaces  covered  with  the  omen- 
tum to  prevent  recurrence.  There  is  danger  of  tearing  the  stomach 
or  opening  a  latent  perforation.  If  the  pylorus  be  constricted  or  an 
ulcer  be  present,  the  operation  should  be  completed  by  a  gastro- 
enterostomy. 

Bilocular  stomach  (hour-glass  stomach)  may  be  congenital,  but  is 
usually  due  to  the  cicatricial  contraction  of  a  peptic  ulcer  on  the 
lesser  curvature;  it  may  be  caused  also  by  perigastric  adhesions, 
cancer,  syphilis,  tuberculosis,  corrosive  poisons,  and  certain  opera- 
tions, e.g.,  gastrostomy  and  partial  gastrectomy.  Biloculation 
resulting  from  the  pressure  of  an  extragastric  tumor  is  sometimes 
called  false  hour-glass  stomach.  We  have  operated  on  one  patient 
with  a  trilocular  stomach.  The  symptom's,  when  the  constriction  is 
small,  are  those  of  chronic  gastrectasia,  the  cardiac  pouch  being 
dilated  owing  to  interference  with  the  onward  passage  of  food. 
Occasionally  the  sulcus  may  be  seen  or  felt  through  the  abdominal 
wall,  and  an  X-ray  picture  taken  after  an  opaque  meal  will  show  the 
outlines  of  the  stomach  (Fig.  392),  or  at  least  the  cardiac  pouch. 


696  MANUAL    OF    SURGERY 

A  diagnosis  must  never  be  made,  however,  from  a  single  skiagram, 
as  a  typical  picture  of  an  hour-glass  contracture  may  result  from  a 
localized  spasm  of  the  muscular  coat.  Repeated  plates  on  different 
days  should  be  taken  or  the  stomach  watched  with  the  fluoroscope. 
The  spasm  will  sometimes  cease  after  massage,  the  application  of 
heat  or  the  administration  of  atropin.  Mediogastric  spasm  may  be 
due  to  the  same  causes  as  pylorospasm  as  well  as  to  organic  pyloric 
stenosis  {vide  infra).  If  the  cardiac  pouch  is  filled  with  fluid,  a 
swelling  on  the  left  side  of  the  abdomen  may  be  seen,  which  gradually 
passes  to  the  right  side,  perhaps  with  an  audible  gurgle,  as  the  fluid 
passes  through  the  constriction.  In  some  cases  fluid  injected  into 
the  stomach  can  only  partly  be  recovered,  although  a  splashing 
sound  persists,  and  after  a  time  a  large  quantity  of  semi-digested 
food  may  be  returned  through  the  tube.     The  diagnosis  is  confirmed 


Fig.  377.  Fig.  378. 

Fig.    377. — Mediogastric    resection.      The    part    to    be    removed    is    indicated    by- 
dotted  lines.      Note  situation  of  the  ulcer. 

Fig.  378. — Mediogastric  fesection,  gastric  segments,  anastomosed. 

by  exploratory  laparotomy,  and  one  must  be  careful  to  examine  the 
whole  stomach,  otherwise  a  pyloric  stenosis  or  a  constriction  near 
the  cardiac  orifice  will  be  missed.  Volvulus  of  the  pyloric  pouch 
has  been  reported  in  several  instances. 

The  treatment  depends  upon  the  site  and  nature  of  the  obstruc- 
tion or  obstructions,  the  state  of  the  ulcer  (whether  active  or  healed) , 
the  size  and  mobility  of  the  pouches,  and  the  general  condition  of 
the  patient.  If  the  stricture  is  the  result  of  carcinoma  it  must,  if 
possible,  be  excised.  In  the  remarks  which  follow  the  hour-glass 
deformity  is  supposed  to  be  due  to  its  usual  cause,  i.e.,  a  peptic 
ulcer. 

Circular,  or  mediogastric  resection  (Figs.  377,378)  is  the  operation 
of  choice.  It  removes  the  ulcer  with  the  constriction  and  reestab- 
lishes the  normal  contour  of  the  stomach.  It  may,  however,  be 
impracticable  owing  to  the  large  size  of  the  ulcer,  the  small  size  of 


ABDOMEN 


697 


one  of  the  pouches,  extensive  adhesions,  or  to  the  poor  condition  of 
the  patient,  the  operation  being  longer  and  more  difficult  than  some 
of  the  procedures  mentioned  below.  In  order  to  guard  against 
recurrence  the  resection  must  include  a  wide  segment  of  the  stomach. 
Pylorectomy  (P'ig.  379)  might  be  done  when  the  constriction  is 
near  the  pjdorus,  especially  if  the  pylorus  also  be  stenosed,  but  is 


Fig.  379.  Fig.  380. 

Fig.  379. — Pylorectomy.      Dotted  lines  indicate  the  part  to  be  removed. 
Fig.    380. — Gastro-gastrostomy.      The   openings   shown    by   the    shaded   areas  are 
anastomosed. 

generally  contraindicated  because  of  its  magnitude  (See  "Pylorec- 
tomy"). 

Gastroga^trostomy  (Fig.  380)  may  be  performed  when  the  pouches 
are  large,  of  nearly  the  same  size,  and  pliable  at  the  points  selected 
for  the  anastomosis. 

Gastroplasty  without  excision  of  the  ulcer  may  be  employed  when 
the  constriction  is  narrow,  and  when  that  portion  of  the   gastric 


Fig.  381. — Gastroplasty  without 
excision  of  ulcer. 


Fig.  382. — Gastroplasty.     In- 
cision closed. 


wall  which  is  to  be  reconstucted  is  freely  movable  and  not  indurated. 
The  isthmus  may  be  incised  in  its  axis,  and  the  incision  sutured 
perpendicularly  (Fig.  381,  382),  or  the  pouches  below  the  isthmus 
may  be  incised  and  sutured  (Figs.  383,  384),  using  the  same  technic 
as  in  the  Finney  operation  (Cf.  "Pyloroplasty"). 

Gastroplasty  with  excision  of  the  ulcer  may  be  selected  when  the 


698 


MANUAL    OF    SURGERY 


ulcer  is  active  and  not  too  large.     The  operation  is  illustrated  by- 
Figs.  385,  386,  and  described  under  '"'Partial  Gastrectomy." 


Fig.    383. — Gastroplasty     Fig.  384. — Gastroplasty.      Fig.  385. — Gastroplasty  with 
without  excision  of  ulcer.  Incision  closed.  excision  of  the  ulcer. 

Gastroenterostomy  (Fig.  387)  is,  as  a  rule,  the  best  operation  for 
the  obstruction  when  the  cardiac  pouch  is  very  large,  or  when  medio- 


PiG.  386. — Gastroplasty. 
Incision  closed. 


Fig.  387. — Single  gastro- 
enterostomv. 


gastric  resection  is  inadvisable,  and  it  or  pyloroplasty  must  be  com- 
bined with  mediogastric  resection,  gastrogastrostomy,   or  gastro- 


Fig.  388. 


Fig.  389. 


Fig.  388. — Double  gastroenterostomy. 

Pig.  389. — Diagram  of  posterior  gastroente  ostomy.     Dotted  lines  indicate  retro- 
gastric  portion  of  bowel  and  site  of  anastomosis.     A,  origin  of  jejunum. 

plasty  when  these  operations  are  performed  in  cases  of  bilocular 
stomach  with  pyloric  stenosis.     Double  gastroenterostomy  likewise 


ABDOMEN"  699 

could  be  used  in  such  cases,  if  the  pyloric  pouch  were  large,  and 
other  methods  contraindicated.  The  bowel  can  be  made  to  run 
from  right  to  left  as  shown  in  Fig.  387,  or,  by  using  a  longer  loop, 
from  left  to  right  (isoperistalic) ,  and  in  either  single  or  double 
gastroenterostomy  the  jejunum  may.  if  the  posterior  operation  is 
inapplicable,  be  attached  to  the  anterior  wall  of  the  stomach. 
Gastroenterostomy  for  its  influence  in  healing  the  ulcer,  or,  if  the 
ulcer  has  been  excised,  preventing  its  recurrence,  is  advised  by  some 
surgeonsas  an  addition  to  circular  resection,  gastrogastrostomy,  and 
gastroplasty,  even  when  the  pylorus  is  open. 

Stenosis  of  the  pylorus  may  be  congenital  (p.  699)  or  acquired, 
organic  or  functional,  extrinsic  or  intrinsic.  The  extrinsic  organic 
causes  are  perigastric  adhesions,  kinking  of  the  pylorus  as  the  result 
of  prolapse  of  the  stomach,  and  compression  by  aneurysm,  tumors, 
cysts,  or  inflammatory  aft'ections  of  the  kidney,  liver,  pancreas, 
gall-bladder,  or  lymph  glands.  The  intrinsic  organic  causes  are 
cicatricial  contraction  (ulcer,  tuberculosis,  syphilis,  caustics), 
tumors,  and  foreign  bodies.  Functional  stenosis,  or  pylorospasm 
likewise  may  be  due  to  a  lesion  in  another  abdominal  organ,  notably 
cholecystitis  and  appendicitis,  to  toxins  (nicotin,  lead,  morphin, 
etc),  to  tabes,  and  to  emotional  causes,  or  intrinsic,  i.e.,  due  to 
disease  of  the  stomach,  especially  ulcer  and  hyperchlorhydria. 
The  symptoms  are  those  of  dilatation  of  the  stomach  plus  in  some 
cases  the  detection  of  a  tumor  at  the  pylorus.  The  treatment  of  extrin- 
sic organic  stenosis,  is  removal  of  the  cause,  or,  if  such  be  impossible, 
gastroenterostomy.  Intrinsic  organic  stenosis  may  demand  gas- 
trotomy,  e.g.,  for  a  foreign  body;  pylorectomy,  e.g.,  for  carcinoma 
or  gastroenterostomy,  e.g.,  for  cicatricial  stenosis  or  irremovable 
carcinoma.  Pyloroplasty  is  occasionally  performed,  for  cicatricial 
stricture.  Pylorospasm  may,  according  to  its  etiology,  require 
medical  treatment,  gastroenterostomy,  or  an  operation  on  an 
abdominal  organ  other  than  the  stomach. 

Stenosis  of  the  cardiac  orifice  (see  "stricture of  the  esophagus")- 
Dilatation  of  the  stomach  (gastr ectasia)  may  be  acute  or  chronic. 
Acute  dilatation  of  the  stomach  is  a  sudden  paralytic  distention 
of  uncertain  origin,  but  probably  the  result  of  disturbed  innervation. 
About  40  per  cent,  of  the  cases  arise  after  operation,  usually  on 
the  upper  abdomen  (hence  shock,  sepsis,  purgation,  handling  of 
the  viscera,  and  the  anesthetic  have  been  held  responsible),  20  per 
cent,  during  exhausting  fevers  (typhoid,  pneumonia,  etc.),  10  per 
cent,  after  errors  in  diet,  particularly  the  ingestion  of  enormous 
quantities  of  food  or  drink,  and  a  few  from  no  condition  which  can 


700 


MANUAL    OF    SURGERY 


be  connected  with  the  gastric  paralysis.  The  associated  conditions 
distributed  among  the  remaining  cases  are  trauma,  emotional 
attacks,  childbirth,  peritonitis,  intestinal  paralysis  (q.v.),  and  spinal 
deformity,  especially  when  there  is  lordosis,  which  may  encourage 
pressure  on  the  duodenum.  The  enormously  dilated  stomach  forces 
the  small  intestine  into  the  pelvis  and  renders  its  mesentery  taut. 
As  a  consequence  the  duodenum  is  compressed  between  the  root  of 
the  mesentery  and  the  superior  mesenteric  vessels  in  front  and  the 
vertebral  column  behind.  _  Some  surgeons  regard  this  constriction 
of  the  duodenum  as  primary,  hence  the  terms  gastromesenteric  ileus 
and  arteriomesentric  occlusion.     Even  if  this  is  not  true,  it  is  certain 


Pig.   390. — Acute  dilatation  of  stomach  following  compotind  fracture  of  femur. 

that  a  secondary  factor  is  thus  added  which  serves  to  augment 
and  perpetuate  the  condition.  The  symptoms  are  pain;  profuse 
vomiting;  severe  thirst;  distention  of  the  stomach,  which  interferes 
with  the  action  of  the  heart  and  lungs,  and  which  may  be  so  great 
as  to  fill  the  whole  abdomen;  gastric  splashing  sounds  on  succusion; 
absence  of  visible  and  audible  gastric  peristalsis,  constipation, 
perhaps  with  clay-colored  stools;  scanty  urine;  and  finally  collapse, 
with,  if  proper  treatment  is  not  quickly  administered,  death  in  two- 
thirds  of  the  cases.  The  diagnosis  from  peritonitis  is  made  by  the 
absence  of  fever,  leukocytosis,  tenderness,  and  rigidity.  In  high 
intestinal  obstruction  there  is  little  or  no  distention. 

The  treatment  is  gastric  lavage;  no  food  or  water  by  mouth. 


ABDOMEN 


701 


placing  the  patient  on  the  right  side  with  the  pelvis  elevated,  in  the 
knee-chest  posture,  or  prone,  in  order  to  relieve  the  duodenum  of 
pressure;  water  by  rectum,  or  salt  solution  subcutaneously  or  intra- 
venously; strychnin,  atropin,  pituitarin,  or  escrin  salicylate  hypo- 
dermically;  electricity  to  the  epigastrium;  and,  as  a  last  resort, 
gastrostomy  or  gastroenterostomy. 

Chronic  dilatation  is  usually  the  result  of  pyloric  stenosis,  but 
may  be  caused  also  by  duodenal  obstruction  (e.g.,  from  ulcer,  cancer, 
and,  in  enteroptosis,  compression  by  the  superior  mesenteric  vessels), 
overeating,  chronic  gastritis,  and  general  malnutrition  {atonic 
dilatation).     The  symptoms  are  dyspepsia,  often  hunger  and  thirst, 


Antrum 

or 
Pylorus/  X, 


Bulb  ofJ)uoae??.um, 
Pi/lorus 


Gas 
dudble 


.  UmbiUcus. 


Fig.  391. — Diagram  of  X-ray  shadow  of  normal  stomach  after  barium  meal,  patient 

standing. 


and  vomiting  at  intervals  of  large  quantities  of  decomposing  food, 
some  of  which  has  lain  in  the  stomach  for  several  days.  The  patient 
emaciates,  passes  small  quantities  of  urine,  is  constipated,  and  may 
have  attacks  of  tetany.  Examination  of  the  stomach  contents  re- 
veals the  sarcina  ventriculi  and  many  other  bacteria;  the  amount  of 
hydrochloric  and  lactic  acids  will  depend  upon  the  cause  01  the  dilata- 
tion. The  stomach  is  prolapsed  to  below  the  umbilicus,  and  is 
often  visible  through  the  abdominal  wall.  Peristalsis  passing  from 
left  to  right  likewise  may  be  seen  at  times.  On  palpation  the 
cushion-like  resistance  of  the  stomach  may  be  felt,  a  splashing  sound 
often  elicited,  and  in  some  cases  a  tumor  detected  in  the  pyloric 


•J02 


MANUAL    OF    SURGERY 


region.  The  size  of  the  stomach  is  determined  by  percussion, 
after  filling  the  stomach  with  air  or  water;  by  measuring  the  quantity 
of  fluid  which  the  stomach  will  hold;  or  by  gastrodiaphany  (trans- 
illumination by  means  of  an  electric  lamp  passed  into  the  stomach). 
If  the  patient  takes  lo  grains  of  salol,  which  is  decomposed  and 
absorbed  in  the  intestine  only,  salicylic  acid  may  not  appear  in  the 
urine  for  many  hours;  normally  it  should  be  detected  within  one 
hour.  The  absorptive  power  of  the  stomach  is  determined  by 
giving  several  grains  of  potassium  iodid  and  testing  the  saliva  for 
iodin,  which  should  be  found  normally  in  from  ten  to  fifteen  minutes. 


Fig.   392. — Diagram  ot  X-ray  shadow  of  hour-glass  stomach  alter  barium  meal,  patient 

standing. 


The  size,  shape,  position,  and  activity  of  the  stomach  may  be  shown 
also  by  the  X-rays,  after  administering  from  two  to  four  ounces 
of  barium  sulphate  in  a  pint  of  milk  or  koumyss  (Fig.  391).  Nor- 
mally the  stomach  should  be-  free  of  the  barium  in  from  three  to 
six  hours.  Partial  retention  after  six  hours,  however,  is  not  always 
due  to  organic  gastric  disease.  It  may  be  the  result  of  extrinsic 
pylorospasm  {vide  supra).  With  the  fluoroscope  the  peristaltic 
movements  can  be  kept  under  continuous  observation.  A  peristaltic 
wave  normally  passes  over  the  stomach  about  every  twenty  seconds. 
An  increase  in  the  number  of  waves  is  seen  in  stenosis,  and  also 
in   certain   afTections  of   the  nervous   system    (locomotor   ataxia). 


ABDOMEN 


703 


One  would  suspect  organic  stenosis  if  there  were  numerous  waves 
of  great  depth.  Reversed  peristalsis  may  occur  in  stenosis  from 
any  cause.  The  shape  of  the  stomach  is  normal  in  functional 
stenosis,  plate-like,  with  displacement  of  the  pylorus  to  the  right, 
in  organic  stenosis. 

The  treatment  in  atonic  cases  is  medical,  i.e.,  lavage,  regulation 
of  the  diet,  electricity,  etc.  If  medical  treatment  fails,  gastroenter- 
ostomy may  be  performed.  In  those  cases  depending  upon  obstruc- 
tion to  the  outlet  of  the  stomach,  the  treatment  is  that  of  pyloric 
stenosis. 


Fig.  393. — Diagram  of  X-ray  shadow  of 
gastrectasia,  patient  standing. 


Pig.  394. — Diagram  of  X-ray  shadow 
of  stomach  with  carcinoma  of  the  greater 
curvature,  patient  standing. 


Gastroptosis,  or  prolapse  of  the  stomach,  is  usually  secondary 
to  gastric  dilatation,  when  the  symptoms  and  treatment  will  be  those 
of  gastrectasia.  It  forms  part  also  of  the  general  visceral  ptosis 
called  Glenard's  disease.  Primary  or  essential  gastroptosis  is 
probably  very  rare,  and  is  constantly  linked  wuth  dilatation,  from 
kinking  of  the  pylorus,  or  from  pylorospasm  the  result  of  hyper- 
acidity. The  symptoms  are  therefore  usually  those  of  chronic 
indigestion  and  gastric  stasis.  The  position  of  the  stomach  may  be 
determined  by  percussion,  after  filling  the  stomach  with  air  or 
water,  or  by  the  X-ray  (vida  supra).  Volvulus  of  the  stomach 
has    occurred   as   a   complication   of   gastroptosis.     The   treatment 


704  MANUAL    OF    SURGERY 

of  the  essential  form  is  gastroenterostomy,  with  or  without  gas- 
tropexy. 

Carcinoma  of  the  stomach  is  very  frequent,  sarcoma  and  innocent 
tumors  are  rare.  Carcinoma  may  involve  any  portion  of  the  stomach, 
but  most  often  affects  the  pylorus  (60  per  cent.) .  often  starting  from 
an  old  ulcer.  It  is  more  frequent  in  the  male  (55  per  cent.),  and  is 
unusual  before  the  fortieth  year.  It  may  be  of  any  variety,  but  is 
generally  scirrhous  in  nature.  It  always  begins  in  the  mucous 
membrane,  infiltrates  the  remaining  coats  of  the  stomach,  and 
finally  invades  the  surrounding  organs,  particularly  the  liver  and 
pancreas.  The  lymphatic  glands,  especially  those  along  the  lesser 
curvature,  are  invaded  at  an  early  period,  and  distant  metastases 
also  may  occur.  The  ''leather  bottle  stomach"  is  a  diffuse  carcin- 
omatous infiltration  of  the  whole  organ.  The  disease  is  fatal  in  from 
a  few  months  to  two  years  or  longer,  according  to  the  nature  and 
situation  of  the  growth. 

The  S5rmptoms  which  occur  in  both  carcinoma  and  gastric  ulcer 
are,  in  order  to  facilitate  comparison,  listed  in  the  same  order  as  in 
the  description  of  "Peptic  Ulcer  of  the  Stomach."  The  indigestion 
is  not  so  apt  to  be  associated  with  heart  burn.  The  pain, as  a  rule, 
is  not  so  marked  as  in  ulcer,  but  may  be  reflected  in  the  same  way. 
It  is  often  continuous  and  may  not  be  reheved  by  vomiting,  hence 
may  not  appear  at  fixed  periods  after  meals,  although  eating  may 
increase  the  discomfort.  In  some  cases  pain  is  absent.  Tenderness 
also  may  be  absent  and  is  seldom  pronounced.  Muscular  rigidity 
is  almost  never  present.  The  vomiting  may  at  first  be  due  to 
pylorospasm,  but  later  is  generally  the  result  of  gastrectasia  following 
pyloric  stenosis,  consequently  may  occur  only  once  in  24  hours  or 
less  often,  the  vomited  material  being  abundant,  foul  smelling,  and 
containing  particles  of  food  ingested  one  or  more  days  previously. 
When  the  cardiac  orifice  is  involved  the  symptoms  are  those  of 
stricture  of  the  esophagus.  When  neither  orifice  is  involved,  vomit- 
ing may  be  absent  unless  the  tumor  has  caused  an  hour-glass  con- 
traction of  the  stomach.  Occasionally  vomiting  does  not  occur  even 
when  there  is  marked  pyloric  stenosis  with  gastrectasia.  Bleeding 
is  usually  shght.  The  blood,  like  the  food,  stays  in  the  stomach  for 
many  hours,  hence  is  decomposed  and  gives  the  so-called  coffee- 
ground  vomit.  ."Melena  may  occur  when  the  blood  passes  through 
the  pylorus.  The  tumor  can  be  felt  in  60  per  cent,  of  the  cases,  but 
in  only  30  per  cent,  within  the  first  six  months  of  the  onset  of  the 
symptoms.  It  is  most  apt  to  be  palpable  when  situated  at  the 
pylorus  or  along  the  greater  curvature,  and  can  never  be  felt  when 


ABDOMEN  70s 

located  at  the  cardiac  orifice.  The  appetite  is  sometimes  good,  but 
usually  there  is  anorexia.  Intervals  of  good  health  do  not  occur, 
as  in  ulcer;  the  disease  is  progressive,  and  marked  emaciation,  or 
cachexia,  soon  appears. 

The  laboratory  methods  of  diagnosis  are  unreliable  in  the  early 
stages,  and  are  of  the  greatest  value  only  when  the  growth  is  inoper- 
able. At  this  time  examination  of  the  gastric  contents  shows  an 
absence  of  free  hydrochloric  acid  and  an  increase  in  the  amount  of 
lactic  acid,  both  of  which  conditions  may  be  found  in  other  gastric 
diseases.  Microscopic  examination  of  the  stomach  contents  may 
show  small  portions  of  the  neoplasm  and  the  Oppler-Boas  bacilli, 
and  these  bacilli  with  visible  or  occult  blood  may  be  found  in 
the  stools.  The  motor  and  absorptive  powers  of  the  stomach  are 
lessened.  Blood  examination  shows  a  reduction  in  the  hemoglobin 
and  an  absence  of  the  digestive  leukocytosis.  Finally  may  be 
mentioned  the  possibility  of  making  a  diagnosis  by  the  esophago- 
scope,  introduced  into  the  stomach;  by  transillumination  with  an 
intragastric  lamp,  showing  a  tumor  on  the  anterior  wall;  and  by  the 
X-rays,  after  the  ingestion  of  an  emulsion  of  barium,  the  tumor 
appearing  as  a  marked  indentation  in  the  outline  of  the  stomach 
(Fig.  394).  The  early  symptoms  are  indigestion,  distaste  for  food, 
pain,  and  sometimes  vomiting.  If  in  spite  of  careful  medical  treat- 
ment, symptoms  of  this  character  persist  for  a  month  or  longer,  and 
are  associated  with  a  progressive  loss  of  weight,  in  a  patient  past 
forty,  one  should  always  suspect  carcinoma,  and  advise  an  explora- 
tory incision,  which  is  the  most  reliable  diagnostic  measure.  This 
is  the  time  for  successful  surgical  treatment.  Among  the  late  symp- 
toms are  coffee-ground  vomit,  cachexia,  palpable  tumor,  ascites 
(from  invasion  of  the  liver,  portal  vein,  or  peritoneum),  distention 
of  the  superficial  abdominal  veins,  swelling  of  the  legs,  femoral 
phlebitis,  and  jaundice  owing  to  involvement  of  the  common  bile 
duct.  Enlargement  of  the  lymph  glands  at  the  base  of  the  left  neck 
due  to  metastasis  up  along  the*  lymphatics  of  the  mediastinum 
is  a  rare  sign.  Metastases  in  Douglas's  pouch  or  in  the  ovaries 
may  occur,  and  operation  should  never  be  performed  without  first 
making  a  rectal  or  vaginal  examination.  In  addition  to  the  compli- 
cations mentioned  above,  perforation,  grave  hematemesis,  and 
tetany  are  possibilities. 

The  treatment  is  exploratory  incision,  and  if  possible,  removal  of 
the  growth  by  partial  or  complete  gastrectomy.  About  25  per  cent, 
of  permanent  recoveries  can  be  expected  after  early  operation. 
If  the  patient  is  very  weak  and  the  growth  situated  at  the  pylorus, 


7o6  MANUAL    OF    SURGERY 

one  may  perform  gastroenterostomy  and  after  the  patient  has  re- 
gained strength  proceed  with  the  pylorectomy.  In  inoperable 
growths  of  the  cardiac  orifice,  gastrostomy  is  indicated  for  the  pur- 
poses of  feeding.  In  inoperable  cancer  of  the  pylorus  gastroentero- 
stomy may  be  performed,  in  order  to  allow  the  passage  of  food  into 
the  bowel.  The  average  duration  of  life  after  this  operation  is  six 
months.  When  the  entire  stomach  is  hopelessly  invaded,  the 
only  possible  measure  which  promises  relief  is  jejunostomy,  or  the 
making  of  an  artificial  opening  into  the  jejunum  in  order  to  feed 
the  patient. 

Gastritis  obliterans  {plastic  linitis  fibromatosis  of  the  stomach) 
is  a  rare  affection,  characterized  by  great  thickening  of  the  walls  of 
the  stomach  as  the  result  of  hyperplasia  of  the  submucosa,  and  a 
progressive  diminution  in  the  size  ot  the  stomach.  It  is  a  cirrhotic 
inflammation,  the  cause  of  which  is  unknown.  It  has  been  attributed 
to  syphilis,  tuberculosis,  or  chronic  ulceration,  and  some  believe  it  to 
be  a  precancerous  lesion.  The  symptoms  are  pain,  vomiting  im- 
mediately after  taking  food,  and  emaciation.  The  small  size  of 
the  stomach  can  be  shown  by  the  X-ray.  The  treatment  is -^ylovo- 
plasty  or  gastroenterostomy,  when  the  pyloric  portion  is  chiefly 
involved;  or  partial  or  complete  gastrectomy. 

Volvulus  of  the  stomach  also  is  rare.  It  may  be  associated  with 
diaphragmatic  hernia,  bilocular  stomach,  or  gastroptosis,  in  each  of 
which  a  sort  of  pedicle  is  formed,  around  which  the  stomach  may 
rotate.  The  symptoms  are  pain,  shock,  and  the  appearance  of  a 
tender,  rounded  tympanitic  swelling  in  the  upper  abdomen.  Vomit- 
ing cannot  occur.  The  treatment  is  laparotomy,  reduction  of  the 
twist,  and  shortening  of  the  gastrohepatic  omentum.  Kocher 
collected  i8  cases  in  which  operation  had  been  performed,  with  13 
recoveries. 

OPERATIONS  ON  THE  STOMACH 

Gastric  lavage  is  required  in  cases  of  poisoning,  as  a  preHminary 
to  operations  on  the  stomach,  and  as  a  therapeutic  measure  in  many 
gastric  diseases,  particularly  dilatation.  The  stomach  tube  is 
lubricated  with  glycerin,  guided  over  the  epiglottis  by  the  forefinger, 
and  pushed  into  the  stomach  while  the  patient  makes  efforts  at 
swallowing.  Water  or  other  fluid  is  then  poured  into  the  funnel  end 
of  the  tube  until  the  requisite  amount  has  been  introduced,  when  it  is 
carried  to  a  lower  level  than  the  stomach,  while  still  full  of  liquid, 
thus  syphoning  off  the  contents  of  the  stomach.  The  washing  may 
be  continued  until  the  stomach  is  clean. 


ABDOMEN 


707 


Gastrotomy,  or  incision  into  the  stomach,  may  be  performed  for 
exploratory  purposes,  gastric  hemorrhage,  the  removal  of  foreign 
bodies  from  the  esophagus  or  stomach,  the  excision  of  benign  tumors 
springing  from  the  inner  walls  of  the  stomach,  and  for  the  dilatation 
of  stricture  of  either  the  cardiac  orifice  or  the  pylorus.  A  median 
abdominal  incision  is  made,  and  the  stomach  drawn  into  the  wound, 
isolated  with  gauze,  and  incised  at  the  desired  point.  The  wound 
is  sutured  with  catgut,  passing  through  all  the  coats,  and  over  this 
is  placed  a  layer  of  Lembert  sutures  of  silk.  The  abdomen  is  closed 
without  drainage.  The  patient  begins  to  take  water  after  the  vomit- 
ing has  ceased,  and  solid  food  at  the  end  of  two  or  three  weeks. 

Gastrostomy  is  the  making  of  an  opening  into  the  stomach, 
for  the  purpose  of  feeding  a  patient.  It  may  be  temporary,  e.g., 
when  performed  to  facilitate  convalescence  after  laryngectomy  or 


Fig.  395. — Witzel's  gastrostomy, 
(Binnie.) 


Pig.   396. — The  Stamm-Kader  gastro- 
stomy.     (Binnie.) 


operations  on  the  esophagus,  or  permanent,  e.g.,  when  performed 
upon  a  patient  with  inoperable  stricture  of  the  esophagus.  The 
opening  should  permit  feeding,  prevent  the  external  leakage  of  the 
gastric  contents,  and  be  as  near  the  cardiac  orifice  as  possible. 

Hartmann  and  others  make  a  vertical  incision  through  the  outer 
border  of  the  left  rectus,  retract  the  inner  portion  of  the  muscle 
towards  the  right,  and  open  the  posterior  sheath  and  peritoneum 
near  the  middle  line.  A  cone  of  the  stomach  is  pulled  through  the 
wound,  and  sutured  to  the  parietal  peritoneum  and  the  skin.  The 
apex  of  the  cone  is  opened,  and  the  patient  fed  with  a  rubber  tube. 

In  the  Frank  operation  a  two  inch  incision  is  made  below  and 
parallel  with  the  left  costal  margin,  then  a  cone  of  the  stomach  is 
drawn  through  this  incision,  and  passed  upwards  under  the  skin  to  a 
second  incision,  about  one  inch  in  length,  situated  over  the  costal 
margin.     The  stomach  is  sutured  to  the  muscles  of  the  first  incision. 


7o8 


MANUAL    OF    SURGERY 


and  to  the  skin  of  the  second  incision,  where  it  is  opened  and  a  tube 
inserted. 

In  Witzel's  operation  the  abdomen  is  opened  through  the  left 
rectus,  a  catheter  passed  into  the  stomach  through  a  small  opening 
and  there  sutured  with  catgut,  and  a  canal  formed  about  the  tube  by 
suturing  the  walls  of  the  stomach  over  it  with  Lembert  sutures 
(Fig.  395).  The  outer  opening  of  the  canal  is  sutured  to  the  parietal 
peritoneum  and  the  abdomen  closed.  This  is  the  best  method  for 
temporary  gastrostomy,  as  the  canal  quickly  becomes  obliterated 
after  the  catheter  is  withdrawn. 


';-^_:%'  ^-V., 


<- 


Fig.  397. — Gastrostomy.     The  cutaneous  incision. 

The  Stamm-Kader  operation  is  shown  in  Fig.  396. 

The  author's  method  for  establishing  a  permanent  gastrostomy 
is  described,  in  the  Transactions  of  the  American  Surgical  Associa- 
tion for  1918.  as  follows:  "An  incision  is  made  from  a  point  just 
below  and  to  left  of  the  ensiform  cartilage  downward  parallel  to  the 
median  line  for  three  or  four  inches.  About  two  or  two  and  a  half 
inches  to  the  left  of  this  incision  a  second  cut  is  made,  the  upper  end 
of  which  is  on  a  level  with  the  upper  end  of  the  first  incision,  the  lower 
end  of  which  is  on  the  level  with  the  lower  end  of  the  first  incision. 
The  lower  extremities  of  these  incisions  are  connected  by  a  trans- 
verse incision  (Fig.  397) .  The  rectangular  cutaneous  flap  thus  outlined 
is  dissected  free,  as  far  as  its  base,  from  the  subjacent  deep  fascia, 
and  the  two  long  margins  sutured  together  with  catgut  over  a  cathe- 
ter rXo.  20  F.),  the  eve  of  which  remains  uncovered  below  thelower 


XHDOMEN 


709 


end  of  the  flap  (Fi^.  398).  'I'he  catheter  with  its  enveloping  skin  is 
drawn  to  one  side,  the  underlying  rectus  muscle  split  longitudinally, 
and  a  portion  of  the  anterior  wall  of  the  stomach  drawn  from  the 


Fig.   398. — Gastrostomy.      Formation  of  the  dermal  tube. 


Fig.   399.— Gastrostomy   envelopement   of   the   dermal   tube    by    the   anterior   gastric- 
wall. 

abdominal  cavity.  A  small  transverse  opening  is  made  in  the 
exposed  gastric  w^all  the  inferior  extremity  of  the  catheter  pushed 
into  the  stomach  through  the  opening,  and  the  rim  of  the  lower  end 


710  MANUAL    OF    SURGERY 

of  the  dermal  tube  enveloping  the  catheter  sutured  with  catgut  to  the 
edges  of  the  opening  in  the  stomach.  The  lower  half  of  the  dermal 
tube  is  buried  in  the  wall  of  the  stomach  in  the  same  manner  as  the 
catheter  is  buried  in  the  Witzel  operation  (Fig.  399) .  The  upper  end 
of  the  canal  thus  formed  by  the  inversion  of  the  anterior  wall  of  the 
stomach  is  sutured  to  the  abdominal  wall,  and  the  split  rectus 
muscle  approximated  with  catgut  around  the  upper  half  of  the 
dermal  tube.  The  skin  about  the  raw  surface  which  remains  is 
undermined,  and,  beginning  at  the  lower  left  corner  of  the  oblong 
defect  (Fig.  397,  B),  sutured,  the  sutures  being  inserted  farther 
apart  on  the  right  (i.e.,  on  the  line  BCD,  Y'lg.  397)  than  on  the  left 
{BA,  Fig.  397),  until  the  lower  margin  of  the  external  orifice  of  the 


Fig.  400. — Gastrostomy.      The  cutaneous  incision  closed. 

dermal  tube  is  reached,  when  the  suture  line  bifurcates  to  embrace 
the  new  stoma.  The  scar  thus  resembles  a  Y,  the  long  tail  of  which 
is  slightly  convex  toward  the  median  line  (Fig.  400).  The  catheter 
is  fastened  to  the  skin  with  a  catgut  suture  and  should  remain  in 
place  until  the  completion  of  healing,  after  which  it  may  be  with- 
drawn, to  be  reinserted  only  at  the  time  of  the  feedings. 

This  method  of  gastrostomy  is  designed  for  those  patients,  usually 
suffering  from  irremovable  oesophageal  carcinoma,  who  must  for  the 
rest  of  their  lives  be  nourished  through  an  artificial  opening  in  the 
stomach.  The  operation  is  a  trifle  longer  than  the  Witzel  operation, 
but  has  all  the  advantages  of  providing  a  canal  lined  with  epithe- 
lium,  which   will   not   become   agglutinated   during   the   intervals 


ABDOMEN  -  711 

between  the  insertions  of  the  catheter.  Further,  there  is  no  danger, 
as  in  the  Witzel  operation,  of  leakage  between  the  outer  end  of  the 
canal  in  the  stomach  and  the  abdominal  wall,  and  no  danger  of 
pushing  the  catheter  between  the  stomach  and  the  abdominal  wall 
and  so  into  the  peritoneal  cavity. 

A  canal  lined  by  mucous  membrane  can  be  constructed,  as  sug- 
gested by  Depage,  Jianu,  and  others,  from  a  f^ap  of  the  wall  of  the 
stomach,  and  is  to  be  preferred  to  all  other  methods  of  gastrostomy 
when  one  desires  to  build  an  artificial  esophagus,  which,  later,  is  to  be 
joined  to  the  external  stoma  of  the  canal  leading  into  the  stomach, 
but  in  the  majority  of  cases  of  oesophageal  occlusion  the  building  of  a 
new  oesophagus  is  not  indicated,  and  to  fashion  amucosa-linedcanal 
from  the  gastric  parietes  is  more  complicated  and  attended  by  greater 
risks  of  infection  than  is  the  operation  described  above  (see  "Eso- 
phagoplasty  ") . 

In  the  Ssbanejew-Franck  operation,  which  also  provides  a  lining 
of  mucous  membrane  for  the  canal  opening  into  the  stomach,  one 
must  often,  in  view  of  the  small  size  of  the  stomach  consequent  upon 
the  oesophageal  obstruction,  pull  almost  the  whole  stomach  from  the 
peritoneal  cavity,  before  exposing  the  requisite  amount  of  gastric 
wall  to  complete  the  operation,  thus  producing  serious  deformity. 
In  addition,  the  external  orifice  of  the  canal  retracts  beneath  the 
skin  and  becomes  difficult  of  access,  thus  rendering  catheterization 
uncertain  and  attempts  at  catheterization  dangerous. 

Gastroplication  consists  in  lessening  the  size  of  the  stomach  by  the 
introduction  of  inversion  sutures  into  its  anterior  wall.  It  is  doubt- 
ful if  this  operation  should  ever  be  employed. 

Gastropexy  also  is  of  doubtful  value.  The  stomach  has  been 
sutured  to  the  anterior  abdominal  wall  and  to  the  liver.  Beyea 
shortens  the  gastrohepatic  and  gastrophrenic  ligaments  by  the  intro- 
duction of  reefing  sutures. 

Gastroenterostomy,  or  the  formation  of  a  fistula  between  the 
stomach  and  the  intestine,  is  indicated  in  pyloric  stenosis,  gastrecta- 
sia,  and  gastric  ulcer.  The  intestine  may  be  united  with  the  anterior 
or  the  posterior  gastric  wall,  or,  as  will  be  explained  under  "Pylorec- 
tomy,"  with  both  walls. 

Anterior  gastroenterostomy,  or  Wolfler's  operation  (Fig.  401), 
is  indicated  in  cases  in  which  the  posterior  operation  is  not  applicable, 
e.g.,  because  of  disease  of  the  posterior  wall,  short,  fatty  mesocolon,  or 
adhesions,  and  in  cases  of  malignancy  in  which  every  minute  should 
be  saved.  Its  disadvantages  are  that  the  long  loop  of  intestine 
attached  to  the  stomach  may  cause  obstruction  by  pressure  on  the 


712  MANUAL    OF    SURGERY 

transverse  colon,  by  allowing  adjacent  coils  of  bowel  to  slip  into 
the  noose,  or  by  producing  angulation  of  the  intestine  on  either  side 
of  the  anastomosis,  that  the  segment  of  jejunum  forming  the  loop 
is  excluded,  physiologically,  from  the  rest  of  the  digestive  tube,  and 
that  peptic  ulcer  of  the  jejunum  (q.v.)  is  more  apt  to  occur  than  after 
the  posterior  operation.  After  opening  the  abdomen  in  the  middle 
line  above  the  umbilicus,  the  omentum  is  pulled  upwards,  and  a  loop 


Pig.  401.- 


Proper  position  for  opening  in  stomach.     A.   Improper  position,  allowing 
formation  of  intragastric  pouch.      (Mayo.) 


of  jejunum,  about  a  foot  from  the  duodenum,  brought  up  over  the 
transverse  colon  and  anastomosed  with  the  lowest  point  on  the 
anterior  wall  of  the  stomach  (Fig.  401),  using  the  same  technic, 
in  regard  to  clamps  and  suturing,  as  in  the  posterior  operation; 
the  Murphy  button  and  the  McGraw  elastic  ligature  are  no  longer 
employed.  The  incision  in  the  stomach  should  be  so  arranged  as  to 
avoid  sharp  angulation  of  the  intestine;  it  may,  according  to  the 
position  of  the  stomach,  be  parallel  with  or  perpendicular  to  the 


ABDOMEN  71,^ 

greater  curvature.  The  intestine  should  run  from  the  patient's  left 
towards  the  right  (isoperistaltic).  The  stomach  should  be  attached 
to  the  bowel  with  a  few  additional  sutures  on  each  side  of  the  ojiening 
in  order  to  ])revent  a  sharp  kink.  Kocher  places  the  afferent  limb 
of  intestine  posteriorly  and  invaginates  its  wall  transversely,  in 
order  to  form  a  valve  which  will  direct  the  stomach  contents  into 
the  efferent  limb  of  intestine. 

Posterior  gastroenterostomy,  or  Von  Hacker's  operation,  has 
advanced  to  its  present  state  of  elliciency  largely  through  the  labors 
of  Peterson,  Czerny,  Mikulicz,  Moynihan,  and  Mayo.  The  gastric 
opening  should  be  at  the  lowest  point  of  the  posterior  wall  of  the 
stomach,  in  the  same  plane  as  the  cardiac  orifice,  and  directed 
obliquely  from  above  downward  and  from  the  patient's  right  to 
left,  in  order  to  avoid  angulation  of  the  jejunum,  which  normally 
passes  in  this  direction  Fig.  389.  Hartmann,  however,  states  that 
when  the  anastomosis  is  made  in  the  cardiac  portion  of  the  stomach 
the  gastric  contents  flow  through  the  pylorus,  when  in  the  pyloric 
antrum,  which  is  the  motor  part  of  the  stomach,  they  pass  almost 
entirely  through  the  anastomosis.  The  opening  in  the  intestine 
should  be  longitudinal  and  opposite  the  mesentery,  as  near  the 
origin  of  the  jejunum  as  possible,  usually  from  two  to  four  inches, 
thus  utilizing  that  portion  which  normally  lies  immediately  behind 
the  stomach  and  avoiding  a  loop.  Clamps  whose  blades  are  covered 
with  rubber  tubing,  are  placed  on  the  intestine  and  the  stomach, 
to  prevent  extravasation  of  contents  and  bleeding  during  the 
operation  which  is  performed  as  follows:  The  abdomen  is  opened 
by  a  four  inch  incision,  separating  the  fibers  of  the  right  rectus 
muscle.  The  transverse  colon  and  omentum  are  turned  up  over 
the  epigastrium,  and  the  mesocolon  torn  through  at  a  bloodless 
spot  within  the  loop  of  the  middle  colic  artery.  A  fold  of  the 
posterior  wall  of  the  stomach  is  drawn  through  this  opening  and 
clamped  with  long  forceps,  the  heel  of  which  should  include  a 
portion  of  the  greater  curvature,  the  great  omentum  being  separated 
slightly  for  this  purpose  (Fig.  402).  The  jejunum  just  below^  its 
origin  is  found  by  carrying  the  finger  along  the  root  of  the  transverse 
mesocolon  to  the  left  of  the  spine,  brought  to  the  surface,  and 
clamped,  the  heel  of  the  clamp  grasping  the  caudal  portion  of  the 
loop.  Unless  care  is  taken  to  apply  the  clamps  in  the  proper  direc- 
tion the  upper  portion  of  the  intestinal  loop  may  be  approximated 
to  the  lower  portion*  of  the  stomach,  thereby  producing  a  twist  in 
the  loop.  After  replacing  the  colon  and  the  omentum  in  the  abdo- 
minal cavity  the  clamps,  with  the  handles  in  the  same  direction, 


714 


MANUAL    OF    SURGERY 


are  laid  side  by  side  and  surrounded  by  gauze  pads.  With  a  con- 
tinuous Lembert  suture  of  silk  or  celluloid  thread  the  stomach  is 
sutured  to  the  intestine  for  at  least  three  inches.  Both  the  stomach 
and  intestine  are  now  incised  down  to  the  mucous  membrane,  about 
one-fourth  of  an  inch  in  front  of  the  suture  line.  The  mucous 
membrane  exposed  by  the  retraction  of  the  outer  coats  is  excised 
and  the  stomach  united  to  the  intestine  all  around  the  anastomotic 
opening  by  a  continuous  catgut  suture,  passing  through  all  the  coats 
in  order  to  give  firm  apposition  and  stop  bleeding  (Fig.  403).  The 
clamps  are  now  removed  and  the  continuous  Lembert  suture  con- 


FiG.  402. — Showing  posterior  vrall  of  the  stomach  drawn  through  a  rent  in  the  trans- 
verse mesocolon.  Note  slight  separation  of  gastrocolic  omentum  from  its  attachment  to 
the  stomach,  permitting  anterior  wall  of  stomach  to  appear,  and  insuring  drainage  at 
lower-most  level.  Black  lines  mark  site  of  proposed  anastomosis;  the  jejunum  shows 
at  its  origin.      (Mayo.) 

tinued  around  the  opening  to  its  point  of  origin.  The  edges  of 
the  tear  in  the  mesocolon  are  fastened  to  the  stomach  to  prevent 
hernia,  and  the  abdomen  closed  without  drainage.  After  operation 
the  patient  is  put  in  the  semi-sitting  posture  and  fed  as  after  gas- 
trotomy.  The  mortality  of  gastroenterostomy  in  benign  cases  is 
3  per  cent,  in  malignant  cases  20  per  cent.,  most  of  the  deaths 
being  due  to  pneumonia,  exhaustion,  and  peritonitis,  the  last 
resulting  from  leakage  of  the  anastomosis,  particularly  in  those 
•with,  carcinomatous  cachexia.  Secondary  operation  is  required  in 
about  5  per  cent,  of  the  cases. 


ABDOMEN 


7^5 


In  the  author's  method  of  gastroenterostomy  the  stomach  is 
emptied  In'  lavage  shortly  before  the  induction  of  anesthesia  "The 
posterior  wall  ot  the  stomach  is  exposed,  as  in  the  ordinary  oper- 
ation of  retrocolic  gastroenterostomy,  by  tearing  through  the 
mesocolon.  A  celluloid  suture  is  passed  through  the  posterior 
wall  of  the  stomach  at  or  near  the  greater  curvature,  and  through 
the  antimesenteric  border  of  the  jejunum  several  inches  from  the 
duodenojejunal  juncture.  Upward  traction  on  this  suture  causes 
the  stomach  and  the  intestine  to  fall  together.  A  second  suture 
then  unites  the  apposed  viscera  at  a  point  three  inches  from  the 
original  suture,  i.e.,  three  inches  nearer  the  duodenojejunal  juncture. 


Fig.    403. — Forceps   in    place    and   anastomosis   half   completed   by    suture.      (Mayo.) 

The  first  suture  is  drawn  towards  the  patient's  left  shoulder,  the 
second  toward  the  patient's  right  hip,  thus  lifting  the  parts  to  be 
anastomosed  from  the  abdomen  and  bringing  them  into  taut  align- 
ment. These  sutures  may  be  confided  to  an  assistant  or  kept  tense 
by  attaching  to  each  a  pair  of  heavy  forceps.  The  fine  of  contact 
between  the  stomach  and  the  intestine  is  now  made  permanent 
by  a  continuous  seroserous  suture,  extending  from  the  lower  guide 
suture  to  the  upper  guide  suture,  and  tied  at  the  latter  point,  the 
end,  however,  being  left  long  for  use  during  the  final  step  in  the 
anastomosis  (Fig.  404) .  After  shielding  the  general  peritoneal  cavity 
from   contamination  by  means   of  an   encircling  gauze  pad,    the 


7i6 


MANUAL    OF    SURGERY 


peritoneal  coat  of  the  stomach  is  incised  close  to  and  parallel  with 
the  line  of  suture,  thus  exposing  the  blood-vessels  which,  with  a 
small  bite  of  the  underlying  mucous  membrane,  as  yet  unopened, 
are  secured  wath  haemostats  at  each  edge  of  the  incision  (Fig.  405). 
The  number  of  h^mostats  required  varies  with  the  length  of  the 


incision  and  the  vascularity  of  the  part.  The  average  is  from  live 
to  six  on  each  side  of  the  incision.  A  smaller  number  is  shown  in 
the  illustration  for  the  purpose  of  clarity.  The  mucosa  is  incised 
between  the  rows  of  forceps,  thus  opening  the  stomach.  Additional 
haemostats  may  be  needed  to  control  minute  vessels  which  could 
not  be  seen  before  the  incision  into  the  stomach  was  made.     A 


ABDOMEN 


717 


gauze  pad  is  laid  over  the  gastric  incision,  and  the  row  of  forceps 
nearer  the  intestine  reflected  on  to  the  gauze.  In  the  same  way 
as  in  dealing  with  the  stomach  the  outer  coat  of  the  intestine  is 
incised,  the  vessels  caught  with  haemostats  (Fig.  406).  the  mucosa 
opened,  and  the  opening  covered  with  a  gauze  pad.     This  leaves 


IMM 


.^^m  % 


the  posterior  wound  edges  exposed.  Each  pair  of  vessels  (one 
gastric  vessel,  one  intestinal  vessel)  in  these  exposed  edges  is  ligated 
with  a  single  strand  of  chromicized  catgut,  after  drawing  the  edges 
together  by  means  of  the  two  forceps  (one  on  the  stomach,  one  on 
the  intestine)  in  closest  proximity  (Fig.  407).  These  ligatures  not 
only  prevent  bleeding  but  also  hold  the  edges  in  firm  apposition. 


7i8 


MANUAL    OF    SURGERY 


If  a  haemostat  does  not  stand  in  close  relationship  with  a  fellow, 
an  additional  forceps  may  be  employed  to  establish  this  relationship. 
After  removing  the  gauze  pads  which  lay  over  the  gastric  and  the 
intestinal  openings  the  anterior  edges  of  these  openings  are  drawn 
together  by  ligatures,  beginning  at  the  end  farthest  from  the  surgeon. 


The  two  forceps  which  lie  opposite  each  other  are  held  by  an  as- 
sistant. The  right  end  of  the  ligature  is  passed  around  the  forceps 
on  the  intestine  from  right  to  left,  the  left  end  around  the  forceps 
on  the  stomach  from  left  to  right;  thus  the  ends  emerge  between 
the  forceps,  beneath  the  loop  of  the  ligature  (Fig.  408).  The  forceps 
are  brought  parallel  to  the  long  axis  of  the  wound,  rolled  toward  each 


ABDOMEN 


719 


Other,  thus  inverting  the  mucous  edges  of  the  wound,  the  ligature  tied, 
and  the  forceps  removed.  Each  succeeding  pair  of  vessels  is  dealt 
with  in  a  similar  manner.  The  result  is  the  same  as  with  the  posterior 
wound  edges,  i.e.,  haemostasis  is  assured  and  the  edges  are  bound 
firmly   together.     The   rest   of   the   proceeding   is   much   like   that 


■■j^    2 


usually  followed.  The  seroserous  suture  is  continued  along  the 
anterior  portion  of  the  anastomosis  and  tied  at  its  point  of  origin 
(Fig.  409).  The  margins  of  the  rent  in  the  mesocolon  are  fastened 
to  the  stomach  or  the  intestine.  The  operation  is  easier  to  perform 
and  less  dangerous  than  gastroenterostomy  in  which  clamps  are 
employed.     After     the     first     guide     suture     has    .been     inserted 


20 


MANUAL    OF    SURGERY 


the  structures  to  be  joined  are  already  in  juxtaposition  and  there 
is  no  risk,  even  for  the  beginner,  of  confusing  the  relations  of  the 
parts,  such  as  is  possible  during  the  apphcation  of  clamps  and  their 
subsequent  adjustment.  Among  the  unreported  disasters  following 
gastroenterostomy  there  are  no  doubt  some  which,  thanks  to  in- 


vi-.  >•.".••'.  .-yt,- 


S.«-*^V 


■'-'%^ 


#. . 


^ 


I 


■-•-'* 


experience  and  clamps,  result  from  suturing  the  lower  end  of  the 
intestinal  opening  to  the  upper  end  of  the  gastric  opening.  One 
of  the  stated  advantages  of  clamps  is  that  they  steady  and  hold 
together  the  concerned  viscera.  As  a  matter  of  fact  the  stomach 
and  the  intestine  are  necessarily  separated  by  the  intervening  blades 
of  these  instruments,  whereas  guide  sutures  not  only  permit  direct 


ABDOMEN 


721 


apposition,  but  at  the  same  time  create  a  ridge  at  the  line  of  contact 
which  facilitates  suturing.  'J'he  same  degree  of  close  alignment 
is  obtained  for  the  anterior  seroserous  suture,  after  the  anterior 
wound  edges  have  been  inverted  by  the  ligatures.  When  clamps 
are  employed  the  mucous  membrane  pouts,  being  squeezed  out  by 


o 


,^^ 


pressure,  and  is  usually  excised.  This  excision  is  not  needed  in 
the  operation  without  clamps.  Suturing  of  the  anterior  edges  of 
the  mucous  membrane,  even  after  the  clamps  have  been  rotated 
toward  each  other,  is  more  difificult  than  the  application  of  ligatures 
as  described  above.  Further,  one  draws  less  stomach  and  less 
intestine  from  the  abdomen  when  using  guide  sutures  instead  of 

46 


72  2  MANUAL    OF    SURGERY 

clamps,  or,  to  put  it  in  other  words,  a  longer  anastomosis  can  be 
made  with  the  aid  of  guide  sutures  than  can  be  made  with  the 
same  amount  of  stomach  and  intestine  when  clamps  are  employed, 
a  consideration  which  occasionally  is  of  some  importance. 

The  danger  of  leakage  of  gastric  or  intestinal  contents  during 
the  operation  is  no  greater,  perhaps  even  less,  than  when  clamps 
are  applied.  Contusion  or  crushing  of  the  tissues  in  the  immediate 
vicinity  of  the  anastomosis  is  avoided.  Damage  of  this  nature  is 
potent  for  evil,  especially  in  the  old,  the  arteriosclerotic,  the 
cachectic.  The  possibility  of  clamp  injury  predisposing  to  peptic 
ulcer  of  the  jejunum,  or  causing  necrosis  at  the  site  of  anastomosis, 
although  remote,  is  nevertheless  real,  and  must  be  included  in  the 
evidence  against  the  clamp.  The  greatest  menace,  however,  is 
that  of  bleeding  after  the  clamps  have  been  removed.  Like  a 
tourniquet,  the  clamp  increases  the  tendency  to  oozing  of  blood, 
after  the  removal  of  the  compression,  and  when  clamps  are  em- 
ployed in  gastroenterostomy  the  hemorrhage,  if  all  the  severed  vessels 
have  not  been  closed,  remains  undiscovered  until  the  patient  vomits 
the  blood  or  presents  evidences  of  acute  anemia.  One  is  then  con- 
fronted with  the  alternative  of  waiting  hopefully,  or  of  reopening 
the  abdomen,  during  a  critical  period,  in  order  to  arrest  the  bleeding. 
Even  carefully  applied  sutures  are  uncertain,  so  far  as  haemostasis 
is  concerned,  unless  the  wound  is  inspected  after  the  clamps  have 
been  removed,  since  even  large  blood-vessels,  unseen  because 
empty,  may  readily  be  punctured  by  the  needle.  In  the  operation 
described  above  the  surgeon  ties  all  the  open  blood-vessels,  and 
may  assure  himself  that  haemostasis  is  complete  (Trans,  Amer. 
Surg.  Assoc,  1917). 

The  vicious  circle  is  a  term  applied  to  the  passage  of  stomach 
contents  into  the  afferent  limb  of  gut,  thence  back  into  the  stomach, 
which  is  emptied  by  vomiting.  Kocher's  method  for  preventing 
this  accident  has  already  been  mentioned.  In  operations  wdth  a 
loop,  an  anastamosis  may  be  made  between  the  lowest  portion 
and  the  jejunum.  In  addition  to  this  measure  the  afferent  loop 
may  be  ligated  with  silk,  fascia,  etc.,  between  the  two  points  of 
anastomosis,  or  the  pylorus  may  be  closed  (see  Exclusion  of  the 
Pylorus).  In  Roux's  method  "en  Y"  the  jejunum  is  divided,  the 
lower  segment  anastomosed  with  the  stomach,  and  the  upper 
segment  with  the  side  of  the  lower  segment  several  inches  below 
the  stomach.  Excluding  diseases  not  consequent  upon  the  opera- 
tion, acute  and  atonic  gastrectasia,  recurrence  and  cancerization 
of  the  ulcer,  and  "vicious  circle,"  which  is  rare  after  the  no-loop 


ABDOMEN  723 

operation,  persistent  vomiting  following  retrocolic  gastroenteros- 
tomy is  due  to  gastrospasm  the  result  of  peptic  ulcer  of  the  jejunum 
(vide  infra),  to  peritonitis,  or  to  obstruction  the  result  of  kinking 
or  twisting  of  the  bowel,  hernia  of  the  small  intestine  through  the 
mesocolon,  or  contraction  of  the  anastomotic  opening.  The  X-ray 
is  of  great  service  in  differentiating  these  lesions.  Vomiting  due  to 
obstruction  requires  a  secondary  operation  for  the  relief  of  the 
obstruction. 

Peptic  ulcer  of  the  jejunum  may  follow  gastroenterostomy,  owing 
to  the  corrosive  action  of  the  gastric  juice.  It  is  probably  more 
frequent  than  is  generally  thought,  many  cases  being  unrecognized. 
Roojen  (1910)  has  collected  89  cases,  most  of  which  occurred  after 
the  anterior  operation,  the  reason  for  this  being  that  the  upper  portion 
of  the  jejunum,  such  as  is  utilized  in  the  posterior  operation,  is 
more  resistant  to  the  digestive  action  of  the  gastric  juice,  owing  to 
the  presence  of  bile  and  pancreatic  fluid.  The  onset  of  symptoms 
varied  from  ten  days  to  nine  years  after  the  gastroenterostomy.  The 
ulcer  is  usually  in  the  desending  limb  of  bowel,  but  may  attack  the 
anastomosis  itself  or  the  afferent  limb;  in  several  cases  there  were 
multiple  ulcers.  Not  one  occurred  after  gastroenterostomy  for 
cancer,  hydrochloric  acid  generally  being  absent  in  these  cases.  The 
ulcer  may  perforate  into  the  transverse  colon,  into  the  general  peri- 
toneal cavity,  or  it  may  cause  a  localized  peritonitis.  These  cases 
emphasize  the  importance  of  treatment  after  gastroenterostomy, 
particularly  in  the  presence  of  hyperacidity.  Some  of  the  patients 
with  acute  perforation  may  be  saved  by  operation.  In  chronic  cases 
the  ulcer  may  be  excised.  If  this  necessitates  removal  of  the  anasto- 
mosis, the  stomach  and  the  bowel  may  be  closed  separately,  if  the 
original  ulcer  has  healed  and  there  is  no  stenosis  of  the  pylorus.  In 
other  cases  a  new  gastroenterostomy  may  be  made  as  far  from  the 
pylorus  as  possible,  in  order  to  avoid  the  acid-forming  portion  of  the 
stomach.  Temporary  jejunostomy  may  be  indicated  in  patients 
who  are  too  ill  to  stand  a  longer  operation. 

Exclusion  or  occlusion  of  the  pylorus  has  been  performed  to 
break  the  vicious  circle  (vida  supra),  to  promote  the  healing  of  a 
duodenal  fistula,  to  give  ulcers  of  the  pylorus  and  duodenum  com- 
plete rest,  and  to  maintain  the  patency  of  a  gastroenterostomy  open- 
ing, which,  if  the  pylorus  remains  open,  tends,  it  is  said,  to  contract 
and  finally  to  close.  The  last-mentioned  indication  is  of  doubtful 
importance,  since,  although  the  gastric  contents  after  gastroenter- 
ostomy often  prefer  the  old  to  the  new  exit,  it  is  unlikely  that  a 
well-made  anastomotic  opening,  unless  complicated  by  ulceration  at 


724 


MANUAL    OF    SURGERY 


the  suture  line,  would,  even  if  non-functionating,  suffer  oblitera- 
tion. Von  Eiselberg's  unilateral  exclusion  of  the  pylorus  is  effected 
by  dividing  the  pyloric  antrum  between  clamps  and  then  closing 
the  wounds  on  each  side  of  the  division.  Dobbertin  leaves  the 
gastric  wound  open,  and  anastomoses  it,  behind  the  colon,  with 
the  antimesenteric  border  of  the  upper  jejunum.  Bartlett  draws  up 
and  kinks  the  pylorus  with  a  skewer,  clamps  the  base  of  the  loop, 
passes  mattress  sutures  through  the  four  walls  between  the  skewer 
and  the  clamp,  amputates  above  the  sutures,  applies  another  series 
of  stitches  to  the  four  exposed  cut  edges,  and  covers  them  with  a 
continuous  Lembert's  suture.  Biondi  incises  down  to  the  mucosa, 
which  is  separated  as  a  cone  without  being  opened,  ligated  in  two 

places,  and  divided  between  the 
ligatures.  The  ends  are  invagi- 
nated,  and  the  incision  in  the  outer 
coats  closed.  The  operation  has 
been  modified  by  simply  ligating 


Fig.  410. — Heineke- Mikulicz  pylor- 
oplasty. A.  Direction  of  incision  in 
pylorus  B.   Incision  sutured. 


Fig.  411 . — Finney  pyloroplasty,  the 
posterior  sutures  of  silk  and  catgut 
and  the  first  anterior  sutures  of  cat- 
gut inserted. 


the  cone  of  mucosa  with  a  transplant  of  fascia  (Strauss).  Girard 
incises  the  outer  coats  of  the  pylorus  transversely  to  its  long  axis  and 
sutures  parallel  with  the  axis.  The  pylorus  may  be  occluded  by 
puckering  the  outer  coats  with  invagination  sutures  (Doyen),  or  by 
ligation  with  silk  (Kelling),  wire,  aluminium  bands  (Brewer),  etc., 
or  with  a  transplant  of  omentum,  fascia  (Willems),  or  round  ligament 
of  the  liver  (Polya) .  The  value  of  pyloric  closure  as  an  adjuvant  to 
gastroenterostomy  cannot  be  doubted.  Von  Eiselberg's  operation 
is  sure  to  exclude  the  pylorus,  but  it  increases  the  risk  of  death. 
Ligatures  of  foreign  material  usually  cut  their  way  into  the  pylorus, 
which  again  becomes  permeable.  Personally  we  employ  a  strip  of 
fascia  from  the  rectus,  or  the  round  ligament  of  the  liver.  This 
precedure  suppresses,  temporarily  at  least,  the  passage  of  the  irritat- 
ing gastric  contents  over  the  ulcer,  and  does  not  add  to  the  risk  of 
the  gastroenterostomy. 


ABDOMEN  725 

Operations  for  Hour-glass  Stomach  (see  "Bilocular  Stomach")- 

Pyloroplasty  is  used  by  a  few  surgeons  for  benign  pyloric  stenosis. 
The  IIciuckc-Mikulicz  operation  consists  in  making  a  longitudinal 
incision  through  the  stricture  and  suturing  the  wound  transversely 
(Fig.  410).  This  has  been  superseded  by  Finney's  pyloroplasty, 
which  not  only  enlarges  the  pylorus,  but  also  lowers  the  outlet  of  the 
stomach.  After  applying  clamps  to  the  stomach  and  the  duodenum 
the  greater  curvature  of  the  stomach  is  sutured  to  the  posterior 
surface  of  the  duodenum  with  silk.  An  incision  is  then  made  in 
front  of  these  sutures  on  the  inferior  surface  of  the  pylorus  and  con- 
tinued into  the  stomach  and  the  duodenum.  The  posterior,  then 
the  anterior,  Hps  of  this  incision  are  united  by  catgut,  the  clamps 
removed,  and  the  Lembert  suture  continued  anteriorly  as  in  gastro- 
enterostomy (Fig.  41 1) .  Rammstedt's  pyloroplasty  is  described  under 
''Congenital  Stenosis  of  the  Pylorus." 

Gastrectomy  may  be  partial  or  complete. 

Partial  gastrectomy  is  performed  for  ulcer  or  for  localized  tumors 
of  the  gastric  wall.  A  piece  of  the  anterior  wall  of  the  stomach  or  of 
the  greater  curvature  is  easily  excised,  the  wound  being  closed  as  in 
gastrotomy.  Excision  of  a  portion  of  the  lesser  curvature,  e.g.,  for 
ulcer,  is  more  difficult.  The  method  we  have  adopted  is  to  make  an 
opening  in  the  gastrohepatic,  and  another  in  the  gastrocolic,  omen- 
tum. Clamps,  applied  from  below,  are  placed  across  the  whole 
width  of  the  stomach,  on  each  side  of  the  ulcer.  This  is  much  easier 
than  trying  to  isolate  the  ulcer  alone  by  clamping  the  lesser  curvature 
from  above.  The  coronary  vessels  are  ligated  to  the  right  and  the 
left  of  the  ulcer;  the  ulcer  is  excised  by  a  V-shaped  or  an  elliptical 
incision;  the  clamps  are  lifted  and  rotated,  so  as  to  bring  in  contact 
the  peritoneal  surfaces  on  each  side  of  the  incision  in  the  posterior 
wall;  tenaculum  forceps  applied  to  the  inverted  upper  and  lower  ends 
of  the  posterior  incision,  to  maintain  the  inversion  and  prevent 
slipping  of  the  clamps;  the  posterior  peritoneal  surfaces  sutured, 
through  the  anterior  wound,  with  celluloid  thread,  the  posterior 
mucous  surfaces  with  catgut;  then  the  anterior  mucous  surfaces 
with  catgut,  the  anterior  peritoneal  surfaces  with  an  inversion  suture 
of  celluloid  thread.  The  clamps  are  removed,  the  openings  in  the 
omenta  closed.  The  suture  Hne  runs  perpendicularly  to  the  long 
axis  of  the  stomach;  suturing  in  the  opposite  direction  produces  too 
much  narrowing  of  the  gastric  cavity.  Balfour's  cautery-excision 
makes  a  smaller  opening  in  the  stomach  than  the  operation  just 
described.  The  gastro-hepatic  omentum  over  the  ulcer  is  detached, 
the  ulcer  destroyed  with  the  actual  cautery,  the  perforation  thus 


726 


MANUAL   OF    SURGERY 


produced  closed  with  a  double  layer  of  inversion  sutures,  and  the 
suture  line  reinforced  by  sewing  the  detached  omentum  over  it.  If 
there  is  a  large  saddle  ulcer  or  an  hour-glass  constriction  the  entire 
middle  segment  of  the  stomach  may  be  removed  by  circular  resection 
(Fig.  377).  Excision  of  a  portion  of  the  posterior  wall,  e.g.,  for  ulcer, 
may  be  accomplished  after  pushing  the  posterior  wall  through  an 
opening  in  the  gastrohepatic  or  the  gastrocolic  omentum,  or  through 
the  transverse  mesocolon.     When  the  ulcer  is  densely  adherent  Mayo 


Pig.  412. — (Alayo.) 


performs  trans  gastric  partial  gastrectomy.  The  anterior  wall  of  the 
stomach  is  incised,  and  through  the  stomach  the  ulcer  is  removed 
and  the  resulting  wound  sutured.  The  incision  in  the  anterior  wall 
is  then  closed.  Resection  of  the  cardiac  orifice  is  described  under 
"Stricture  of  the  Esophagus."  The  term  pylorectomy  may  mean 
not  only  resection  of  the  pylorus  alone,  but  also  resection  of  the 
pylorus  and  a  large  amount  of  the  stomach.  Perhaps  it  would  be 
better  to  designate  the  latter  as  subtotal  gastrectomy.  These  opera- 
tions are  described  below. 

Pylorectomy  is  usually  performed  for  carcinoma,  occasionally  for 


ABDOMEN 


727 


peptic  ulcer.  Pylorectomy  for  carcinoma  should  remove  the  growth 
and  the  lymphatic  glands  into  which  it  drains,  i.e.,  those  along  the 
lesser  curvature,  and  those  along  the 
greater  curvature  near  the  pylorus.  The 
latter  group  of  glands  drains  the  adjacent 
third  of  the  stomach,  the  lymph  stream 
flowing  from  left  to  right,  hence  the 
absence  of  involvement,  in  pyloric  carci- 
noma, of  the  lymph  glands  along  the  left 
two-thirds  of  the  greater  curvature.  After 
the  pylorus  has  been  removed  there  are 
several  ways  of  restoring  the  continuity  of 
the  gastrointestinal  canal.  In  Brillroth's 
first  method  the  open  end  of  the  duodenum 
was  sutured  to  the  lower  end  of  the  wound 
in  the  stomach,  the  superfluous  part  of  the  stomach  wound  being  closed 
by  sutures;  leakage  often  occurred  where  the  three  lines  of  suture  met. 


Fig.  413.— Polya.  Dotted 
line  site  of  anastomosis. 
Arrow  shows  direction  of  intes- 
tinal current.  A,  origin  of 
jejunum . 


Fig.  414. — (Mayo.) 


The  whole  of  the  gastric  wound  may  be  anastomosed  with  the  side  of 
the  jejunum  by  theantecoHc  (Kroelein)  or  theretrocolicroute  (Polya). 
(Fig.  413.)     The  upper  or  the  lower  part  of  the  gastric  wound  may 


728  MANUAL   OF    SURGERY 

be  closed,  and  the  remaining  portion  anastomosed  with  the  jejunum 
(vide  infra).  In  Kocher's  method  the  stomach  wound  is  closed  and 
the  end  of  the  duodenum  anastomosed  to  the  posterior  gastric  wall. 
In  Billroth's  second  method,  the  procedure  now  generally  employed, 
both  the  wound  in  the  stomach  and  that  in  the  duodenum  are  closed 
and  an  anterior  or  a  posterior  gastrojejunostomy  performed.  Mayo 
describes  the  operation  as  follows:  "Open  the  abdomen  by  a  longi- 
tudinal incision  from  the  ensiform  cartilage  to  the  umbilicus;  ligate 
and  divide  the  gastric  artery  near  the  stomach,  ligate  and  divide  the 
gastrohepatic  omentum  close  to  the  liver  and  tie  the  superior  pyloric 
artery.  Free  the  upper  part  of  the  duodenum  and,  with  the  finger 
as  a  guide  beneath  the  pylorus  in  the  lesser  peritoneal  cavity,  ligate 
the  right  gastroepiploic  or  gastroduodenal  artery.  Tie  and  sever 
the  gastrocohc  omentum  near  the  colon  as  far  as  the  desired  point 
on  the  greater  curvature  and  here  secure  the  left  gastroepiploic 
vessels.  Apply  two  short  clamps  to  the  duodenum,  sever  the  duo- 
denum between  the  clamps  with  the  cautery,  and  close  it  by  a  con- 
tinuous catgut  suture  which  is  buried  by  a  purse-string  suture  of 
silk.  Double  clamp  the  stomach  along  the  Mikulicz-Hartmann  line 
(Fig.  412),  and  sever  between  the  clamps  with  the  cautery.  Close 
the  stomach  by  a  continuous  suture  of  catgut  and  a  continuous 
Lembert  suture  of  silk.     Perform  a  gastrojejunostomy  (Fig.  414)." 

After  abandoning  the  operation  just  described  the  Mayos  tried 
the  Polya  method  (Fig.  413),  in  which  the  beginning  of  the  jejunum 
is  brought  up  through  the  transverse  mesocolon  and  anastomosed 
with  the  whole  length  of  the  opening  left  after  amputation  of  the 
stomach,  and  then  the  Kroenlein  operation,  which  is  the  same  as 
that  of  Polya,  except  that  a  long  loop  of  the  jejunum,  passing  up 
in  front  of  the  colon,  is  used  for  the  anastomosis.  At  the  present 
time  (1919)  they  close  the  lower  part  of  the  gastric  wound,  and 
anastomose  the  upper  part  with  the  side  of  the  jejunum  14  inches 
from  its  origin.  The  apposed  stomach  and  intestine  below  the 
anastomosis  are  sewed  together  in  order  to  reinforce  the  gastric 
suture  line  (Fig.  422).  "The  transverse  colon  naturally  sags  in  its 
mid  portion;  by  turning  the  bowel  from  left  to  right  it  is  brought  to 
the  left  of  the  center,  while  the  stomach  delivers  along  its  lesser 
curvature,  the  more  fixed  portion  of  the  viscus.'"  At  the  Mayo 
clinic  the  mortality  of  resection  of  the  stomach  for  malignant  disease 
is  13.7  per  cent.;  of  the  patients  who  recovered  from  the  operation 
37.6  per  cent,  were  well  after  three  years,  25  per  cent,  after  five 
years  (1919). 

The  author's  method  of  subtotal  gastrectomy  "consists  in  re- 


ABDOMEN 


729 


Fig.  419. 


Fig.  420.  Fig.  421, 

Figs.  415  to  421. — Subtotal  gastrectomy. 


730 


MANUAL    OF    SURGEEY 


moving  the  diseased  segment  of  stomach  from  left  to  right,  after 
performing  an  end-to-side  anastomosis  between  the  lower  portion 
of  the  incision  that  amputates  the  stomach  and  the  upper  part  of  the 
jejunum,  the  operation  being  so  conducted  that  the  suturing  necessary 
to  unite  the  stomach  to  the  intestine  is  completed  before  either  viscus 
is  opened.  The  gastric  artery  is  doubly  Ugated  at  the  upper  end  of 
the  proposed  line  of  section  of  the  stomach,  and  divided  between 
the  Kgatures.  The  gastrohepatic  omentum  is  tied  in  sections  and 
severed.  The  left  gastroepiploic  artery  is  ligated  about  one  half  inch 
on  each  side  of  the  lower  end  of  the  proposed  line  of  section  of  the 
stomach,  and  the  segment  of  artery  between  the  Hgatures  excised. 
The  gastrocolic  omentum  is  tied  and  cut,  from  a  point  about  two 
inches  to  the  cardiac  side  of  the  selected  line  of  gastric  amputation 

to  the  duodenum.  The  transverse 
mesocolon  is  drawn  taut,  without 
pulh'ng  the  colon  from  the  abdomi- 
nal cavity,  and  a  hole  torn  in  this 
membrane,  form  the  upper  side, 
within  the  arc  of  the  midcolic 
artery.  The  upper  end  of  the 
jejunum  immediately  bulges  into 
this  opening  and  is  drawn  into  the 
lesser  peritoneal  cavity.  A  suture 
is  passed  through  the  greater  curva- 
ture of  the  stomach,  midway  be- 
tween the  ligatures  on  the  left 
gastroepiploic  artery,  and  through 
the  antimesenteric  border  of  the 
jejunum,  at  a  point  about  five  or 
six  inches  below  the  origin  of  the  jejunum,  the  distance  varying  ac- 
cording to  the  degree  of  dilatation  of  the  stomach.  By  pulling 
upwards  on  this  suture  the  posterior  wall  of  the  stomach  and  the 
upper  segment  of  the  jejunum  are  brought  in  contact.  A  suture  unit- 
ing the  posterior  wall  of  the  stomach  to  the  intestine  is  inserted  about 
three  inches  above  the  original  suture,  and  a  third  suture  is  passed 
through  the  posterior  wall  of  the  stomach  alone,  an  inch  or  more 
above  the  second  suture  (Fig.  415),  both  of  these  sutures  being  on 
the  line  through  which  the  stomach  is  to  be  amputated.  Two  sutures 
are  now  placed  in  the  anterior  wall  of  the  stomach,  at  points  corre- 
sponding to  the  upper  sutures  in  the  posterior  wall  (Fig.  416).  The 
point  at  which  each  anterior  suture  is  to  be  inserted  may  be  deter- 
mined easily  by  grasping  the  stomach  with  the  left  hand  in  such  a  way 


Fig.  422. — Mayo.  Dotted  lines  in- 
dicate site  of  anastomosis  and  retro  colic 
portion  of  bowel.  Omenta  omitted. 
Arrow  indicates  direction  of  intestinal 
current.     A,  origin  of  jejunum. 


ABDOMEN  731 

that  the  index  finger  presses  the  point  of  insertion  on  the  posterior 
wall  up  against  the  corresponding  point  on  the  anterior  wall,  which 
point  is  marked  by  the  thumb.  Suture  A  is  now  drawn  upwards  to 
the  right  (i.e.,  towards  the  patient's  right  shoulder),  sutures  B  and 
D  downwards  to  the  left  (i.e.,  towards  the  patient's  left  hip)  and 
tied  together,  sutures  C  and  E  likewise  downwards  and  to  the  left 
and  tied  together  (Figs.  417  and  418).  The  upper  segment  of  the 
jejunum  is  thus  surrounded  by  the  stomach,  the  anterior  wall  of  which 
lies  against  the  right  side  of  the  bowel,  the  posterior  wall  against  the 
left  side  of  the  bowel.  Between  sutures  B,  D  and  sutures  C,  E  the 
anterior  and  the  posterior  walls  of  the  stomach  are  in  contact 
which  contact  is  made  permanent  by  the  introduction  of  a  sero- 
serous  suture  of  celluloid  thread,  which  suture  is  continued  from 
B,  D  to  A,  uniting  the  anterior  wall  of  the  stomach  to  the  bowel  and 
from  A  back  to  B,  D,  uniting  the  posterior  wall  of  the  stomach 
to  the  bowel  (Fig.  418).  This  seroserous  suture  is  over  laid  by  a 
through-and-through  catgut  suture,  and  sutures  B  and  D  are  cut  off 
short.  The  greater  curvature  of  the  stomach  is  grasped  with  forceps 
about  one-half  inch  from  A  (Fig.  419),  and  the  lesser  peritoneal  cavity 
filled  with  gauze.  The  portion  of  the  antimesenteric  border  of  the  in- 
testine exposed  between  the  rows  of  sutures  is  excised,  and  an  incision 
made  in  the  stomach  close  to  the  suture  line,  begining  at  G,  passing 
between  A  and  F,  and  ending  at  H  (Fig.  419).  After  ligating  any 
vessels  which  have  not  been  caught  by  the  sutures,  thread  A  is 
cut  and  the  stomach  allowed  to  straighten  itself  (Fig.  420).  A  clamp 
is  placed  across  the  stomach  to  the  pyloric  side  of  the  hne  of  section, 
and  the  amputation  completed  after  approximating  the  anterior  and 
the  posterior  walls  of  the  stomach,  between  J  and  K  (Fig.  420),  by 
several  through-and-through  sutures  of  catgut,  which  sutures  are 
buried  by  an  inversion  seroserous  suture  of  celluloid  thread.  It  is  well 
but  not  essential,  to  insert  the  uppermost  inversion  suture  before 
completing  the  amputation  of  the  stomach,  since  by  pulling  on  this 
suture  the  raw  edges,  which  are  already  inverted  at  the  lower  end 
(J,  Fig.  420),  recede  between  the  serous  coats,  which  can  then  be 
rapidly  sutured  (Fig.  421).  The  pyloric  segment  of  the  stomach  is 
drawn  from  the  abdominal  cavity  and  turned  over  on  the  patient's 
right  hypochondrium,  the  superior  pyloric  and  the  gastroduodenal 
arteries  secured  above  and  behind  the  pylorus,  the  duodenum  severed 
between  ligatures,  and  the  duodenal  stump  inverted.  The  edges  of 
the  rent  in  the  transverse  mesocolon  may  be  attached  to  the  jejunum 
or,  if  there  is  much  gastrectasia,  to  the  stomach.  The  operation 
just  described  may  be  performed  in   any  case  of  gastrectomy  in 


732  MANUAL   OF    SURGERY 

which  posterior  gastroenterostomy  is  appHcable,  and  perhaps  in  some, 
in  which,  owing  to  the  small  size  of  the  gastric  stump,  posterior 
gastroenterostomy  would  be  injudicious.  With  equal  practice  in  the 
two  operations  the  newer  one  should  be  less  difficult  and  more  rapid ; 
there  is  less  cutting  to  be  done,  consequently  less  suturing;  the 
lower  part  of  the  incision  for  amputating  the  stomach  serves  at  the 
same  time  for  the  anastomotic  opening.  In  the  newer  method  the 
anastomotic  opening  is  at  the  lowest  part  of  the  stomach,  and 
all  of  the  anastomotic  sutures  and  a  portion  of  the  sutures  which 
close  the  stomach  above  the  anastomosis,  are  in  place  before  either 
the  stomach  or  the  intestine  is  opened.  When  the  incisions  are  made 
the  cut  edges  are  in  view,  unrestrained  by  clamps  ,so  that  hemostasis 
may  be  made  absolute  '"(trans,  of  the  Amer.  Surg.  Assoc,  1914). 

Complete  or  total  gastrectomy  has  been  performed  twenty-five 
times,  with  thirteen  recoveries.  It  is  indicated  in  the  rare  cases  in 
which  almost  the  entire  stomach  is  cancerous,  but  in  which  the 
surrounding  organs  are  free.  The  greater  and  lesser  omenta  are 
ligated  and  divided  ,aDd  the  entire  stomach  removed  between  clamps. 
The  open  end  of  the  duodenum  is  closed,  and  the  esophagus  anasto- 
mosed to  the  upper  jejunum  with  sutures  or  a  ^Murphy  button. 
In  some  cases  it  may  be  possible  to  anastomose  the  esophagus  to  the 
duodenum. 

THE  INTESTINES 

Ulcer  of  the  duodenimi  is  usually  solitary  and  located  on  the 
anterior  wall  within  two  inches  of  the  pylorus,  at  the  point  where  the 
acid  gastric  contents,  ejected  through  the  pylorus,  strike  the  duo- 
denal mucosa.  It  is  due  to  the  same  causes  and  occurs  twice  as 
often  as  ulcer  of  the  stomach,  is  more  common  in  men  (4  to  i) 
between  the  ages  of  thirty  and  fifty,  and,  unHke  gastric  ulcer,  shows 
little  tendency  towards  carcinomatous  degeneration.  The  symptoms 
are  much  like  those  of  gastric  ulcer,  but  vomiting  is  unusual  unless 
self  induced,  blood  is  more  apt  to  be  passed  by  bowel  than  vomited, 
so  that  serious  bleeding,  although  causing  faintness,  pallor,  etc.,  may 
not  be  suspected  unless  the  stools  are  examined;  the  pain  occurs  sev- 
eral hours  after  eating,  not  infrequently  after  the  patient  has  retired 
for  the  night,  and  is  of  ten  relieved  by  food  (hunger  pain),  probably 
because  the  food  gives  the  hydrochloric  acid  something  to  act  upon 
and  stimulates  the  secretion  of  the  alkaline  duodenal  juices;  and  the 
tender  point  is  just  above  and  to  the  right  of  the  umbilicus  (Fig.  376). 
The  X-ray  after  the  ingestion  of  barium,  shows  no  pylorospasm  but 
rather  incontinence  of  the  pylorus,  the  barium  flowing  at  once  from 


ABDOMEN  733 

the  stomach,  which  may  be  empty  at  the  end  of  two  or  three  hours, 
and  is  always  empty  at  the  end  of  two  or  three  hours,  and  is  always 
empty  at  the  end  of  five  or  six  hours.  The  shadow  cast  by  the 
"cap"  may  show  irregularities  due  to  spasm,  adhesions,  or  ulceration; 
a  notch  with  the  base  towards  the  duodenum  is  seen  only  in  very 
deep  ulcers.  Perforation  is  most  apt  to  occur  when  the  ulcer  is  in 
the  anterior  or  the  right  lateral  wall,  serious  hemorrhage  when  in  the 
posterior  or  left  lateral  wall,  owing  to  the  proximity  of  the  gastro- 
duodenal  artery.  Acute  perforation  is  more  frequent,  but  somewhat 
less  serious,  than  in  gastric  ulcer.  The  contents  of  the  duodenum 
are  relatively  small  and  sterile  and,  when  a  leak  occurs,  tend  to 
gravitate  into  the  right  iliac  fossa  (hence  the  frequency  with  which  a 
diagnosis  of  appendicitis  is  made),  whereas  a  large  quantity  of  the 
gastric  contents  may  be  quickly  diffused  over  the  peritoneal  cavity, 
and  fatal  hemorrhage  may  occur.  The  treatment  of  duodenal  ulcer 
is  that  of  gastric  ulcer.  (For  Curling's  ulcer  of  the  duodenum  see 
"Burns.") 

Wounds  of  the  intestine  (see  "Contusions  and  Wounds  of  the 
Abdomen"). 

Congenital  stenosis  of  the  intestine  may  occur  near  the  common 
bile  duct,  and  in  the  lower  ileum  at  a  point  corresponding  to  the 
situation  of  Meckel's  diverticulum.  Imperforate  anus  is  considered 
on  a  later  page.  Meckel's  diverticulum  is  a  persistent  omphalo- 
mesenteric duct,  which  generally  arises  from  the  ileum  about  three 
feet  above  the  ileocecal  valve.  It  exists  in  2  per  cent,  of  human 
beings.  It  may  open  at  the  umbilicus  {congenital  fecal  fistula,  see 
umbilicus),  or  be  obliterated  in  whole  or  part,  the  obliterated 
portion  persisting  as  a  cord  attached  to  the  umbiHcus,  the  mesen- 
tery, or  other  viscus.  In  many  cases  the  diverticulum  hangs  free  in 
the  peritoneal  cavity,  its  interior  being  Uned  with  mucous  membrane 
and  communicating  with  the  intestine.  The  structure  may  become 
inflamed,  the  symptoms  and  treatment  being  the  same  as  those  of 
appendicitis,  or  it  may  cause  intestinal  obstruction  by  kinking  or 
twisting  the  bowel,  by  invaginating  into  the  bowel  {intussusception}, 
or  by  acting  as  a  band  or  noose  which  constricts  or  ensnares  a  coil  of 
intestine.  Obstruction  is  most  common  in  early  life  and  the  patient 
may  exhibit  other  deformities,  but  there  is  nothing  distinctive  in  the 
symptoms.  The  diverticulum  might  be  shown  by  the  X-ray. 
When  inflamed  or  giving  rise  to  obstruction,  the  diverticulum  should 
be  excised,  and  the  opening  in  the  bowel  closed  with  Lembert  sutures. 

Acquired  diverticula  are  most  frequent  in  the  descending  colon 
and  sigmoid  of  fat  constipated  men  past  middle  life.     They  are 


734  MANUAL    OF    SURGERY 

usually  multiple,  may  be  very  minute  or  as  large  as  a  cherry,  and 
represent  hernial  protrusions  of  the  mucosa  through  the  muscularis, 
often  at  the  point  where  vessels  pierce  the  bowel  wall  to  enter  the 
appendices  epiploicae.  Diverticulitis  often  results  from  the  irrita- 
tion of  a  fecal  concretion.  The  symptoms  of  the  acute  form  are 
those  of  appendicitis,  except  that  the  trouble  is  in  the  left  abdomen 
(Fig.  376).  Perforative  peritonitis  or  localized  abscess,  may  follow. 
In  the  chronic  variety  the  colon  about  the  diverticulum  participates 
in  the  inflammation  and  finally  becomes  thick,  hard,  and  contracted 
causing  symptoms  of  chronic  obstruction,  sometimes  pus  and  blood 
in  the  stools,  and  closely  mimicking  scirrhous  carcinoma.  Car- 
cinoma may  indeed,  coexist  or  be  due  to  diverticulitis.  The  X-ray 
after  an  opaque  enema  may  reveal  the  constriction,  as  well  as  the 
pockets  caused  by  the  diverticula.  The  treatment  of  perforation  is 
suture;  of  abscess,  drainage;  of  stricture,  excision. 

Idiopathic  dilatation  of  the  colon  {Hirschsprung'' s  disease)  may 
occur  at  any  period  of  life,  but  is  usually  of  congenital  origin  and 
most  frequent  in  male  infants.  Although  mild  cases  may  remain 
stationary,  the  disease  generally  progresses,  and  terminates,  in  from  a 
few  weeks  to  many  years,  in  death  from  peritonitis,  toxemia,  or 
pneumonia.  The  whole  colon,  or  only  a  part,  usually  the  sigmoid, 
may  be  involved.  The  bowel  is  greatly  dilated  (the  circumference  in 
one  case  reaching  30  inches),  hypertrophied,  sometimes  elongated, 
often  kinked,  and  frequently  contains  stercoral  ulcers,  which  on 
healing  may  lead  to  stenosis.  The  symptoms  are  obstinate  consti- 
pation (the  bowels  may  not  move  for  weeks),  sometimes  alternating 
with  diarrhea;  emaciation;  possibly  convulsions  or  tetany;  bal- 
looning of  the  abdomen;  diastasis  of  the  recti;  distension  of  the 
superficial  veins;  visible,  audible,  and  palpable  peristalsis;  fore- 
shortening of  the  thorax;  flaring  of  the  costal  margins;  and  inter- 
ference with  the  action  of  the  heart  and  lungs  from  pressure.  Pain, 
tenderness  and  vomiting  are  often  absent.  Indican  may  be  found 
in  the  urine.  The  size,  shape,  and  position  of  the  colon  can  be 
demonstrated  by  the  X-ray,  after  the  administration  of  an  opaque 
enema.  The  treatment  is  at  first  medical,  viz.,  liquid  diet,  tonics, 
strychnin,  colonic  lavage,  electricity  locally,  and  abdominal  massage. 
If  these  measures  fail  appendicostomy  and  daily  irrigations  of  the 
colon,  short  circuiting  of  the  colon  by  ileosigmoidostomy,  or  excision 
of  the  colon  or  its  most  affected  part  may  be  performed.  In  des- 
perate cases  right  inguinal  colostomy  is  indicated,  more  radical 
measures  being  adopted  after  improvement  has  occurred. 

Pericolitis  has  been  explained  in  three  ways.     The  evolutionary 


ABDOMEN  735 

theory  is  that  the  membranous  bands  described  below  develop  to 
support  the  intestine,  which,  owing  to  the  erect  posture  of  man, 
tends  to  gravitate  toward  the  pelvis;  the  developmental  theory  that 
the  bands  result  from  abnormalities  in 'the  rotation  and  descent  of 
the  cecum  (but  the  condition  may  be  found  also  about  the  descending 
colon  and  the  sigmoid) ;  the  infectious  theory  that  the  membranes  are 
due  to  infection  transmitted  through  the  walls  of  the  bowel  to  the 
peritoneal  covering,  as  the  result  of  chronic  colitis  or  colonic  stasis. 
Pericolitis  arising  from  other  causes,  e.g.,  diverticuHtis,  is  not  in- 
cluded under  this  heading.  The  advocates  of  the  infectious  theory 
point  out  that  normally  the  large  gut  is  firmly  attached  at  its 
highest  point,  the  splenic  flexure,  to  the  diaphragm  by  the  short 
phrenocolic  ligament,  and  at  this  point  there  is  a  spur,  because  the 
adjacent  portions  of  the  transverse  and  the  descending  colon  lie  in 
contact,  sometimes  for  a  distance  of  five  or  six  inches.  According 
to  Cannon,  "the  purpose  of  this  arangement  is  to  prevent  the  rapid 
entrance  of  fecal  matter  from  the  upper  portions  of  the  colon  into  the 
sigmoid.  The  function  of  the  former  is  absorptive,  of  the  latter, 
eliminative.  Hence  we  find  that  ordinarily  the  cecum,  ascending 
and  transverse  colon  are  distended  with  fecal  matter  and  gas,  while 
the  sigmoid  is  empty  and  contracted.  A  similar  though  less  pro- 
nounced arrangement  exists  at  the  hepatic  flexure  (Glenard).  The 
resistance  offered  by  the  splenic  flexure  on  one  side,  and  by  the  closure 
of  the  ileocecal  valve  on  the  other,  renders  consecutive  peristaltic 
and  antiperistaltic  locomotion  of  the  intestinal  contents  between 
these  points  possible."  If  this  normal  or  quasi-normal  retardation 
is  exaggerated,  undue  desiccation  takes  place  above  the  splenic 
flexure,  and  habitual  constipation  follows,  with  catarrhal  colitis  and 
bacterial  penetration  of  the  intestinal  wall  (Gerster). 

Pathologically  the  peritoneum  is  thickened,  and  in  places,  notably 
the  cecum,  ascending  colon,  and  splenic  flexure,  adhesions  develop,, 
often  broad  and  membranous  Uacksons  membrane) ,  but  sometimes 
long  and  cord-like.  These  adhesions  interfere  with  normal  peristal- 
sis by  compressing  or  stiffening  the  gut,  or  by  accentuating  the 
normal  flexures  as  the  result  of  the  glueing  together  of  the  adjacent 
segments  ("double-barrel  stenosis"),  thus  rendering  the  constipa- 
tion still  more  obstinate.  Complete  obstruction,  however,  rarely 
occurs. 

The  symptoms  are  those  of  chronic  coHtis,  chronic  constipation, 
autointoxication,  and  neurasthenia.  There  is  general  abdominal  un- 
easiness ,and  sometimes  real  pain  and  tenderness  over  the  cecum, 
w^hich,  when  thickened    and  distended,  can  often  be  outlined  by 


■36 


MANUAL    OF    SURGERY 


palpation.  Occasionally  there  are  sharp  attacks  of  coUcky  pain  in 
this  region,  particularly  after  dietary  indiscretions,  which  attacks 
are  relieved  by  a  free  bowel  movement  or  the  expulsion  of  gas. 
Many  of  these  cases  are  operated  upon  for  appendicitis,  which,  it  is 
true,  not  infrequently  is  associated  with  and  due  to  cohtis.  Removal 
of  the  appendix,  however,  does  not  relieve  the  patient  of  the  colitis  or 
pericolitis,  evidences  of  which  conditions  should  be  sought  for  when- 
ever the  abdomen  is  opened  for  nonsuppurative  lesions  in  the  right 
iliac  fossa.  Willems  thinks  many  of  these  cases  of  cecal  colic  are  due, 
not  to  fixation  of  the  cecum,  but  to  abnormal  laxitv  of  its  attach- 


FiG.  422a. — Diagram  of  X-ray  shadow 
of  normal  colon,  after  barium  ingestion, 
patient  standing. 


Fig.  423. — Diagram  of  X-ray  shadow 
of  colon  in  pericolitis,  patient  standing . 


ments,  a  condition  which  he  calls  cecum  mobile,  and  which  he  treats 
by  attaching  the  cecum  to  the  parietal  peritoneum  (cecopexy). 
Others  beheve  spasm  or  atony  to  be  the  most  important  factor, 
hence  the  terms  typhlospasm.  iypJdatomy,  typhlectasia. 

In  pericolitis.  X-ray  examination,  after  a  barium  meal,  shows 
retention  of  the  bismuth  in  the  cecum,  sometimes  for  24  or  48  hours, 
dilatation  of  the  colon,  and  abnormalities  in  its  position,  e.g.,  ptosis, 
double-barrel  stenosis  (Figs.  422a,  423). 

The  treatment  of  pericoUtis,  is  first  medical  measures  directed 
against  the  chronic  catarrhal  colitis.  If  medical  treatment  fails 
operation  is  indicated,  care  being  taken,  however,  to  exclude  cases 


ABDOMEN  737 

of  neurasthenia  and  hysteria  not  secondary  to  the  condition  under 
discussion.  Even  when  operation  is  undertaken  it  should  be  follow- 
ed by  dietary,  medicinal,  and  hygienic  measures,  if  the  best  results 
are  to  be  obtained.  Usually  an  incision  should  be  made  in  the  right 
iliac  region,  the  appendix  removed,  and  any  restraining  adhesions, 
if  membranous,  severed  transversely  to  the  direction  of  the  adhesions 
and  sutured  longitudinally,  or,  if  cord-like,  ligated  and  divided.  In 
some  cases  the  membranous  film  over  the  cecum  has  been  completely 
detached  and  sutured  behind  the  cecum,  the  resulting  raw  surface 
being  covered  with  peritoneum.  Lane  calls  attention  particularly 
to  adhesions  which  sometimes  are  attached  to  and  drag  upon  the 
lower  end  of  the  ileum,  forming  a  V-shaped  kink.  In  cases  in  which 
the  colon  is  hopelessly  crippled  it  may  be  short  circuited  by  ileo- 
sigmoidostomy  (see  "Exclusion  of  the  Intestine")  or  excised. 
Appendicostomy  or  cecostomy  is  indicated  only  in  severe  ulcerative 
forms  of  colitis. 

Typhoidal  perforation  of  the  intestine  is  probably  responsible 
for  one-third  of  the  fatalities  in  enteric  fever.  The  accident  usually 
occurs  during  the  third,  fourth,  or  fifth  week,  although  it  may 
happen  at  any  stage  of  ,the  disease.  As  a  rule  the  pain  is  sudden 
in  onset,  begins  in  the  right  lower  quadrant  of  the  abdomen,  quickly 
becomes  generalized  and  persists  despite  the  hebetude  of  the  patient. 
Tenderness  is  most  marked  in  the  region  of  the  perforation,  usually 
the  right  iliac  fossa,  and  may  be  elicited  also  on  rectal  or  vaginal 
examination.  Rigidity  of  the  abdominal  muscles  is  the  most  valua- 
ble sign;  it  is  at  first  localized  over  the  area  of  perforation,  thence 
becoming  generalized  with  the  spread  of  the  infection.  The  hard- 
ening of  the  belly  wall  due  to  meteorism,  to  emaciation,  to  the 
application  of  cold  water,  or  to  associated  pulmonary  disease  should 
not  mislead  the  surgeon.  The  remaining  symptoms  are  those  of 
pneumoperitoneum  with  diffuse  peritonitis  (q.v.).  Typhoidal  per- 
foration may  be  confounded  with  almost  any  other  lesion  producing 
a  peritonitis,  with  any  form  of  intestinal  obstruction,  and  with  spon- 
taneous rupture  of  the  spleen,  but  as  the  treatment  of  all  these  cases 
is  laparotomy,  a  failure  to  differentiate  them  is  not  productive  of 
harm.  One  must  be  most  careful,  however,  to  exclude  constipation, 
distention  of  the  urinary  bladder,  catarrhal  cholecystitis,  pleurisy, 
iliac  phlebitis,  and  epididymitis,  all  of  which  may  simulate  perfora- 
tion, and  none  of  which  requires  operation  (cf.  "Unnecessary 
Abdominal  Section"  and  "Diagnosis  of  Appendicitis") .  The  most 
difficult  differential  diagnosis  is  that  between  intestinal  hemorrhage 
and  perforation  as  the  symptoms  are  sometimes  identical;  to  mistake 


738  MANUAL    or    SURGERY 

hemorrhage  for  perforation  means  an  unnecessary  operation  at  a  very 
critical  period,  to  mistake  perforation  for  hemorrhage  means  death. 
Blood  in  the  stools  is  not  conclusive,  since  the  two  conditions  may 
coexist.  A  reduction  in  the  number  of  red  cells  and  in  the  hemo- 
globin would  point  towards  hemorrhage,  leukocytosis  and  a  rise  in 
the  blood  pressure  towards  perforation.  Pneumoperitoneum,  if  pro- 
nounced, might  be  shown  by  the  X-ray.  Opium  should  be  withheld 
in  cases  of  hemorrhage  in  which  perforation  is  suspected,  because  of 
the  danger  of  clouding  the  symptoms. 

The  treatment  is  immediate  operation.  Pain,  rigidity,  and 
tenderness  always  demand  exploration,  which  may  be  conducted 
under  local  anesthesia.  If  the  diagnosis  is  confirmed,  ether  should 
be  employed,  as  the  operation  can  be  performed  more  quickly, 
without  subjecting  the  patient  to  the  deleterious  effects  of  fright  and 
struggling.  If  shock  is  present  the  danger  of  delay  far  outweighs 
the  danger  of  a  rapid  operation.  The  incision  is  made  in  the  right 
iliac  region,  as  90  per  cent,  of  all  perforations  are  found  in  the  last 
twenty  or  thirty  inches  of  the  ileum  or  in  the  cecum  or  appendix.  If 
the  perforation  is  not  found  in  the  ileum  and  there  are  evidences  of 
peritonitis,  the  sigmoid,  the  colon,  and  the  remaining  portion  of 
the  small  intestine  should  be  explored  in  the  order  mentioned.  The 
perforation  should  be  sutured  with  a  double  row  of  Lembert  sutures 
of  silk,  without  excising  the  ulcer.  A  large  perforation  may  be 
sutured  obhquely,  so  as  not  to  interfere  with  the  fecal  current. 
Search  for  a  second  perforation  should  always  be  made,  as  in  18 
per  cent,  of  the  cases  the  openings  are  multiple.  All  suspicious  spots 
should  be  treated  as  perforations.  In  some  cases  suture  is  impossible 
because  of  the  size  of  the  opening,  the  number  of  openings,  or  because 
of  gangrene  of  the  bowel.  Resection  in  these  cases  consumes  so 
much  time  that  surgeons  have  been  afraid  to  try  it.  Plugging  the 
hole  with  omentum,  or  suturing  the  omentum  over  the  perforation 
has  been  suggested,  and  isolation  of  the  affected  portion  of  bowel  by 
gauze  packing  may  sometimes  be  used.  The  safest  plan  is  to  anchor 
the  intestinal  loop  outside  the  abdominal  cavity,  in  order  to  make  the 
isolation  more  complete;  this  will  also  relieve  the  distention  and 
permit  local  treatment  of  the  remaining  typhoid  ulcers.  After 
dealing  with  the  perforation,  the  treatment  is  that  of  the  diffuse 
peritonitis  (q.v.) .  The  author  has  operated  upon  forty  patients  with 
typhoidal  perforation  of  the  intestine;  fifteen  recovered. 

Tuberculosis  of  the  intestine  is  most  frequent  in  the  lower  ileum 
and  in  the  cecum,  probably  because  the  slow  fecal  current  in  this 
region  permits  the  deposition  of  the  bacilli.     There  are  two  forms. 


ABDOMEN  739 

The  cnlero- peritoneal  form  is  the  result  of  active  caseation.  There 
is  little  or  no  tendency  towards  healing,  hence  stricture  does  not 
occur.  A  subacute  abscess  forms  in  the  right  iliac  fossa  and  this 
may  finally  break  externally,  often  through  one  of  the  hernial  rings, 
and  eventuate  in  a  fecal  listula.  Diarrhea  with  blood  and  mucus 
in  the  stools  is  caused  by  ulceration  of  the  mucosa,  and  phthisis  is 
frequently  present.  The  hyperplastic  form  arises  when  the  repara- 
tive forces  are  in  excess.  The  tubercles  are  encased  in  dense  fibrous 
tissue,  which  converts  the  gut  into  a  thick,  rigid,  contracted  tube. 
The  mucous  membrane  is  ulcerated  and  the  lymph  glands  enlarged. 
The  symptoms  are  those  of  chronic  obstruction,  with  a  hard,  movable, 
cylindrical  mass  in  the  right  iliac  fossa.  In  either  form  of  intestinal 
tuberculosis  the  bacilli  may  be  found  in  the  stools.  The  treatment 
is  excision.  When  this  is  impossible  the  affected  segment  may  be 
short  circuited  by  ileosigmoidostomy. 

Splanchnoptosis,  or  Glenard^s  disease,  is  a  displacement  down- 
wards of  the  abdominal  viscera,  and  includes  gastroptosis,  enteroptosis, 
hepatoptosis,  splenoptosis,  nephroptosis,  retrodisplacement  or  pro- 
lapse of  the  uterus,  and  sometimes  cardioptosis  owing  to  displacement 
of  the  diaphragm.  The  most  important  cause  is  relaxation  of  the 
abdominal  wall,  which  may  be  congenital,  or  the  result  of  trophic 
changes,  pregnancy,  ascites,  and  like  conditions.  Traumatism, 
corsets,  and  kyphosis  also  have  been  held  responsible  for  this  condition. 
It  is  much  more  common  in  women  than  in  men.  The  S3miptoms 
are  usually  those  of  dyspepsia  and  neurasthenia,  although  they  vary 
according  to  the  organ  which  is  most  affected.  The  abdomen  is  flat 
above  and  prominent  below,  the  wall  flabby,  and  the  recti  often 
widely  separated.  The  displaced  organs  may  be  palpated,  or  out- 
lined by  percussion.  The  gastrointestinal  canal  is  often  narrowed 
at  its  most  fixed  points.  This  fact,  with  the  position  and  activity 
of  the  stomach  and  intestines,  can  be  determined  by  X-ray  examina- 
tion, after  the  administration  of  barium.  Stiller's  sign  is  abnormal 
mobility  of  the  tenth  rib.  The  treatment  is  the  application  of  an 
abdominal  support,  massage,  electricity,  tonics,  and  often  lavage 
of  the  stomach.  If  these  measures  fail,  the  fascia  between  the  recti 
may  be  excised  and  these  muscles  sutured  together,  in  order  to  lessen 
the  size  of  the  peritoneal  cavity  and  tighten  the  abdominal  wall. 
One  or  more  of  the  displaced  structures  may  be  fastened  in  place. 
In  enteroptosis  the  splenic  and  hepatic  flexures  of  the  colon  have 
been  fastened  to  the  abdominal  wall.  Operations  for  the  fixation  of 
other  organs  are  mentioned  in  the  sections  treating  of  these  organs. 
When  intestinal  stasis  is  a  prominent  feature  Lane  performs  ileosig- 


740 


MANUAL   OF   SURGERY 


moidostomy  (end-to-side)  and,  if  there  has  been  much  pain,  resects 
the  colon  down  to  the  anastomosis. 

Intestinal  obstruction,  or  ileus,  may  be  true  (mechanic)  or  false 
(intestinal  paralysis).  True  obstruction  may  be  classified,  from  an 
etiologic  standpoint,  as  shown  in  the  subjoined  table. 


I. 

Bands  and  adhesions. 

2. 

Apertures  (including  hernia) 

3- 

Volvulus  (included  here  be- 

A 

Compression 
(rarely  traction), 
from  causes  out- 

cause the  obstruction  is  due 
to  an  adjoining  segment  of 
bowel) . 

side  the  intestine 

4- 

Extraintestinal  tumors  and 
viscera  other  than  the  intes- 

Causes of 

tine. 

intestinal 

I. 

Congenital  strictures. 

obstruction 

B. 

Strictures,  from 

2. 

Cicatricial  strictures. 

causes  in  the 

3- 

Neoplastic  strictures. 

intestinal    wall 

4. 

Spasmodic  strictures. 

C 

Obturation, 

I. 

Foreign  bodies. 

from  causes  in 

2. 

Fecal  impaction. 

the  lumen  of  the 

3- 

Polyps. 

intestine 

4- 

Intussusception. 

The  conditions  enumerated  above  will  be  described  after  a 
general  consideration  of  the  subject  of  intestinal  obstruction. 

The  pathological  changes  in  the  bowel  above  the  obstruction  are 
dilatation,  congestion,  and,  if  the  obstruction  lasts  long  enough, 
hypertrophy  of  the  muscular  coat  and  ulceration  of  the  mucosa,  the 
last  of  which  may  lead  to  perforative  peritonitis,  abscess  formation, 
or  fecal  fistula.  Below  the  obstruction  the  gut  is  pale,  empty,  and 
contracted.  At  the  site  of  obstruction  in  the  first  three  conditions 
in  class  A  and  in  intussuception,  the  intestine  may  be  gangrenous 
from  strangulation  (see  ''Strangulated  Hernia"  for  details);  in  class 
B  it  exhibits  simply  the  changes  incident  to  the  causative  lesion; 
and  in  class  C  it  may  be  ulcerated  from  the  pressure  of  the  obturating 
agent.  The  pressure  exerted  by  extraintestinal  tumors  and  viscera 
other  than  the  intestine  is  seldom  great  enough  to  produce  ulceration 
or  gangrene. 

Clinically  intestinal  obstruction  may  be  divided  into  three  forms, 
the  acute,  the  subacute,  and  the  chronic.  Although  the  symptoms 
may  appear  suddenly  or  gradually  in  any  of  the  conditions  mentioned 
above,  acute  obstruction  is  usually  due  to  the  first  three  causes  in 


ABDOMEN  741 

class  A  or  to  ihc  lust  in  class  H  and  (\  subacute  obstruction  to  the 
tirst  three  in  class  C,  and  chronic  obstruction  to  the  lirst  three  in 
class  B  or  the  last  in  (Mass  A. 

The  symptoms  of  acute  obstruction,  in  which  the  lumen  of  the 
bowel  is  suddenly  and  completely  closed,  e.g.,  in  volvulus,  acute 
intussusception,  and  strangulation  by  bands,  adhesions,  or  apertures, 
are  (i)  those  of  shock,  (2)  those  due  solely  to  the  obstruction,  and 
(3)  those  of  acute  toxemia,  (i)  Shock  generally  indicates  strangula- 
tion, and  is  more  severe,  the  more  sudden  the  onset,  the  higher  the 
obstruction,  the  tighter  the  strangulation,  and  the  greater  the  amount 
of  bowel  involved.  The  shock  passes  after  a  time,  but  the  pulse 
remains  rapid,  and  the  temperature  does  not  rise  above  normal  until 
peritonitis  supervenes,  when  all  the  symptoms  of  this  affection  ensue. 

(2)  The  most  important  symptoms  of  ohstruciion  per  se  are  pain, 
vomiting,  constipation,  increased  peristalsis,  and  tympanites.  The 
pain  is  sudden  in  onset,  due  to  the  strangulation;  severe  and  colicky, 
owing  to  the  violent  peristaltic  movements  of  the  intestine  above  the 
obstructed  point ;  usually  referred  to  the  neighborhood  of  the  umbilicus , 
rarely  to  the  site  of  the  lesion;  and  is  sometimes  relieved  by  but  is 
often  worse  after,  pressure,  also  after  taking  food,  purgatives,  or 
enemata.  General  abdominal  tenderness  and  rigidity  are  absent 
until  the  advent  of  peritonitis,  in  the  later  stages  of  which  pain  and 
peristalsis  are  no  longer  present.  Vomiting  of  the  contents  of  the 
stomach  occur  soon  after  the  onset  of  the  pain,  probably  as  the 
result  of  reflex  nervous  disturbances.  Later,  owing  to  the  obstruc- 
tion, the  material  becomes  bilious  and  finally  stercoraceous,  being 
regurgitated  without  effort.  This  regurgitant  or  gushing  vomiting 
is  characteristic,  and  occurs  earlier  and  is  more  severe,  the  nearer  the 
obstruction  is  to  the  stomach;  rarely,  in  obstruction  of  the  lower  colon 
it  may  be  absent.  As  the  result  of  the  excessive  loss  of  fluid  by 
vomiting  there  are  oliguria,  great  thirst,  and  sometimes  cramps  in 
the  legs.  Indicanuria  occurs  in  many  cases.  Constipation,  if  the 
bowel  below  the  occlusion  is  empty,  becomes  absolute,  not  even  gas 
being  expelled.  Notwithstanding  the  constipation  peristalsis  is 
increased,  and  may  be  felt,  heard  and  occasionally,  if  the  abdominal 
wall  is  very  thin,  seen;  as  a  rule,  however,  visible  peristalsis  indicates 
hypertrophy  of  the  muscular  coat  of  the  bowel,  hence  chronic  ob- 
struction, which,  it  must  be  noted,  generally  terminates  with  acute 
symptoms.  Tympanites  is  due  principally  to  bacterial  decomposi- 
tion of  the  contents  of  the  bowel  above  the  point  of  obstruction. 
The  lower  the  obstruction,  the  greater  the  distention  of  the  abdomen. 

(3)  Acute  toxemia  is  due  to  absorption  of  the  decomposing  intestinal 


742  MANUAL    OF    SURGERY 

contents,  or  to  peritonitis  as  the  result  of  gangrene  or  perforation  of 
the  gut,  hence  represents  the  final  stage,  or  the  stage  of  collapse,  in 
which  the  symptoms  are  those  of  exaggerated  shock  (q.v.).  If 
unrelieved,  acute  obstruction  usually  causes  death  within  a  week, 
as  the  result  of  toxemia,  exhaustion,  or  interference  with  the  intra- 
thoracic organs  from  tympanites.  Although  rare,  spontaneous 
recovery  is  possible;  thus  a  fistula  may  connect  the  bowel  above  and 
below  the  obstruction  or  empty  externally,  a  foreign  body  may  pass, 
a  kink  be  straightened,  or  the  invaginated  portion  of  an  intussuscep- 
tion may  slough  and  separate. 

The  diagnosis  is  seldom  difficult,  but  the  seat  and  cause  are  often 
undetermined    until    an  exploratory  incision  has   been  made.     In 
acute  gastrectasia   (q.x.)  intestinal  peristalses  is  not  exaggerated, 
the  stomach  is  dilated,  and  the  distension  subsides  after  gastric 
lavage.     Intestinal  paralysis  (q.v.)  differs  from  obstruction  in  the 
absence  of  peristalsis,  and  the  presence  of  the  symptoms  of  the  causa- 
tive lesion,  both  before  and  after  the  onset  of  obstructive  symptoms; 
thus  in  peritonitis  there  will  be  fever,  rigidity,  leukocytosis,  etc. 
The  seat  of  obstruction  may  occasionally  be  located  by  the  palpation 
of  a  mass  through  the  rectum,  vagina,  or  abdominal  wall,  or  by  the 
situation  of  the  pain,  tenderness,  or  area  of  active  peristalsis.     The 
greater  the  distention,  the  later  the  vomiting  of  stercoraceous  mate- 
rial, and  the  larger  the  amount  of  urine  excreted,  the  lower  in  the 
intestine  is  the  obstruction.     When  tympanites  is  absent  the  lesion 
is  in  the  upper  small  intestine;  when  confined  to  the  central  portion 
of   the    abdomen,    in  the  lower  ileum;  when  marked  in  the  right 
loin,  in  the  transverse  colon;  and  when  marked  in  both   loins,  in  the 
sigmoid  or  the  rectum.     Tenesmus  generally  indicates  a  lesion  of  the 
large  bowel.     Rectal  injections  of  air  or  water  for  the  purpose  of 
diagnosis  are  not  recommended.     It  is  said  that  if  sLx  quarts  of  water 
can  be  introduced,  the  obstruction  is  in  the  small  intestine;  if  but  a 
pint  or  quart,  in  the  rectum  or  sigmoid.     Aside  from  conditions 
that  may  cast  a  shadow  the  X-ray  may  indicate  the  site  of  the  les- 
ion by  revealing  the  extent  of  the  distended  gut  above  the  obstruction. 
TJie  cause  of  obstruction  may  be  an  external  hernia,  which  must  first 
be  excluded  in  all  cases;  if  such  be  found  and  be  irreducible,  it  should 
be  investigated  by  incision.     If  a  hernia  has  been  replaced  and  the 
symptoms  continue,  the  possibility  of  a  reduction  en  bloc,  i.e.  reduc- 
tion without  relief  of  strangulation,  should  be  recalled.     Excluding 
hernia  the  most  common  cause  of  intestinal  obstruction  is,  in  the 
new-born,  imperforate  anus;  in  infants,  intussusception  or  adhesions 
due  to  tuberculous  peritonitis;  in  adults,  bands,  adhesions,  or  vol- 


ABDOMEN  743 

Villus;  in  old  age  carcinoma  of  the  bowel  or  fecal  impaction.  Severe 
collapse  indicates  a  tight  strangulation.  The  previous  history  should 
be  eUcited  particularly  with  reference  to  biliary  colic,  chronic  consti- 
pation, peritonitis,  abdominal  operations,  tuberculosis,  syphilis, 
dysentery,  and  pelvic  disorders.  The  distinguishing  features  of  the 
various  forms  of  obstruction  are  noted  in  the  description  of  the 
individual  diseases  responsible  for  the  obstruction. 

The  treatment  is,  with  few  exceptions, abdominal  section.  While 
preparations  are  being  made  for  operation,  morphin  should  be  given 
hypodermatically  to  quiet  peristalsis,  the  stomach  emptied  by  lavage, 
and  the  rectum  evacuated  by  an  enema  unless  such  has  already  been 
done.  Purgatives  are  contraindicated.  In  the  absence  of  a  definite 
diagnosis  as  to  the  point  of  obstruction,  the  abdomen  should  be 
opened  in  the  median  line  below  the  umbiUcus.  If  the  cecum  is  dis- 
tended, explore  the  sigmoid;  if  the  sigmoid  is  collapsed,  the  obstruc- 
tion is  in  the  large  bowel  between  it  and  the  cecum.  If  the  cecum 
is  collapsed,  it  will  be  necessary  to  follow  the  small  bowel  until 
the  obstruction  is  found.  Another  rule  is  to  select  the  most  dilated 
and  congested  coil  of  bowel  and  follow  it  in  the  direction  of  the  in- 
creasing congestion  and  distention.  In  the  most  urgent  cases  no 
attempt  should  be  made  to  find  the  seat  of  obstruction,  but  the 
abdomen  opened  under  local  anesthesia,  and  an  artificial  anus  estab- 
lished in  the  first  presenting  distended  coil  of  intestine.  Before  or 
after  dealing  with  the  obstruction,  particularly  in  later  cases  in  which 
peristalsis  is  feeble  or  absent,  the  great  distention  may  be  relieved 
by  incising  one  or  more  coils  of  intestine  and  allowing  the  contents  to 
escape,  subsequently  suturing  the  wounds.  The  obstruction  itself 
is  dealt  with  according  to  its  cause  (vide  infra) . 

In  subacute  obstruction  the  symptoms  are  midway  in  intensity 
and  duration  between  those  of  acute  and  those  of  chronic  obstruc- 
tion. The  initial  shock  is  absent,  but,  in  most  instances,  the  ob- 
struction progresses  until  the  bowel  is  completely  occluded,  when  the 
symptoms  are  those  of  acute  obstruction. 

In  chronic  obstruction  the  gradualy  increasing  constipation  with 
abdominal  uneasiness  is  often  attributed  to  intestinal  indigestion. 
At  irregular  intervals  there  are  colicky  pain,  obstinate  constipation, 
abdominal  distention,  visible,  audible,  and  palpable  peristalsis,  and 
vomiting;  the  last,  however,  is  often  absent  in  stricture  of  the  colon 
until  the  obstruction  becomes  complete.  Purgatives  often  dislodge 
the  impacted  food  or  feces  responsible  for  the  transient  obstruction. 
Diarrhea  may  thus  alternate  with  constipation.  Finally  acute  and 
complete  obstruction  ensues.  The  treatment  is  described  with  the 
diflferent  lesions. 


744  MANUAL    OF    SURGERY 

Bands  and  adhesions  are  a  common  cause  of  intestinal  obstruc- 
tion. Congenital  peritoneal  bands  are  sometimes  encountered, 
notably  in  the  region  of  the  duodenum.  Adhesions  result  from  acute 
or  chronic  peritonitis,  or  from  the  reparative  processes  following 
operation  and  injuries.  They  may  exist  in  any  portion  of  the  perit- 
oneal cavity,  but  are  most  frequent  in  the  four  corners  of  the  abdo- 
men and  in  the  pelvis,  from  lesions  of  the  appendix,  stomach  and 
duodenum  (especially  ulcer),  gall  bladder,  perisplenitis,  diver- 
ticulitis, and  inflammatory  affections  of  the  uterus,  tubes,  and 
ovaries.  These  adhesions  may  be  short  and  numerous,  binding 
adjacent  segments  of  bowel  in  a  V-,  N-  or  W-shape;  they  may  be 
broad  and  membranous,  and  spread  out  over  the  bowel  so  as  to 
interfere  with  its  peristaltic  action  or  to  compress  it  (see  pericolitis) ; 
or  they  ma}'  be  moulded  into  bands,  the  bowel  being  kinked  by 
traction  (rare) ,  or  strangulated  by  passing  under  or  hanging  over  the 

band  or  by  slipping  into  a  noose  formed 
by  the  band  (Fig.  424).  Opportunity 
for  intestinal  strangulation  may  be  pre- 
sented also  when  adhesions  fix  the  free 
end  of  a  pedunculated  tumor  or  cyst 
(usually  ovarian  or  uterine),  or  an 
abdominal  organ,  e.g.,  the  omentum, 
appendix,  appendices  epiploicae.  Fallo- 
pian tubes,  or  ^Meckel's  diverticulum. 

Fig.    424. — Intestinal    obstruction  o.™*--,^^.^-,  1,1.^.  •iU 

from  a  band  of  adhesions.  Symptoms  may  be  absent  even  with 

extensive  adhesions.  When  symptoms 
arise  they  vary  from  the  mildest  form  of  chronic  constipation  to  the 
most  severe  form  of  acute  obstruction.  The  latter  is  generally  due 
to  acute  kinking  or  strangulation  of  a  coil  of  the  small  intestine, 
usually  the  lower  ileum.  Intestinal  obstruction  from  adhesions 
should  be  suspected  if  there  is  a  history  of  previous  peritonitis  or 
of  an  abdominal  operation  or  injury. 

The  treatment  of  obstruction  due  to  limited  adhesions  is  separa- 
tion of  the  involved  coils  of  bowel,  and,  if  possible,  covering  of  the 
raw  surfaces  with  peritoneum.  When  the  intestines  are  extensively 
and  intricately  matted  together,  e.g.,  in  tuberculous  peritonitis, 
an  anastomosis  may  be  made  between  the  bowel  above  and  the  bowel 
below.  If  there  is  strangulation  the  band  should  be  divided  between 
ligatures,  making  sure  that  such  band  is  not  a  ^MeckeFs  diverticulum, 
which  should  be  excised  in  the  same  way  as  the  appendix.  If  the 
bowel  is  gangrenous  it  should  be  treated  as  described  under  strangu- 
lated hernia. 


ABDOMEN  745 

Apertures  arc  rcsj)onsible  for  all  forms  of  hernia  fq.v.).  Abnor- 
mal openings,  either  congenital  or  traumatic,  may  be  found  also  in 
the  omentum  and  mesentery. 

Volvulus,  or  torsion  of  the  intestine,  is  most  common  in  the 
sigmoid  flexure,  then  in  the  small  intestine,  then  in  the  cecum  and 
ascending  colon.  The  bowel  may  be  twisted  on  its  mesenteric  axis, 
the  usual  variety  (Fig.  425),  on  its  own  axis,  or  two  coils  of  intestine 
may  be  twisted  together.  When  the  twist  is  tight  the  circulation  is 
suppressed  and  gangrene  follows. 

Volvulus  of  the  sigmoid  flexure  is  most  frequent  in  constipated 
men  between  forty  and  sixty.  The  sigmoid  is  normally  predisposed 
to  twisting,  in  that  it  forms  a  long  loop  whose  origin  and  termination 
are  closely  approximated,  and  this  predisposition  is  accentuated 
when  the  loop  is  elongated  by  habitual  overdistention,  or  when  its 
limbs  are  drawn  together  at  their  bases  by  cicatricial  contraction  of 
the  mesentery.  As  a  rule  the  proximal  limb 
falls  down  over  the  distal  in  consequence  of 
straining  to  empty  the  bowel,  stooping  to  lift  a 
weight,  or  similar  efforts  involving  a  change  in 
position  and  muscular  exertion,  and  the  twisting 
thus  induced  may  continue  for  two  or  even  three 
complete  turns. 

The  symptoms  usually  appear  very  suddenly, 
although  the  initial  shock  mav  be  less  severe  than  Fig.  425.— Volvulus 
in  most  other  forms  of  acute'  obstruction.  The  l.tUTo^Jhe  w 
distinguishing  features  aside  from  the  age  of  the  and  of  the  bowel  above 

,      ,       ,  .  .      ,  .  .  .  the  obstruction. 

patient  and  the  history  of  chronic  constipation, 
are  late  vomiting;  extreme  distention  of  the  abdomen;  a  rounded 
tympanitic  tumor  in  the  left  iliac  fossa;  and  often  tenesmus,  with- 
out, however  the  passage  of  anything  from  the  rectum.  Death 
generally  occurs  within  two  or  three  days,  from  peritonitis  or  pressure 
on  the  diaphragm.  In  rare  instances  a  partial  twist  may  straighten 
out,  only  to  recur  at  irregular  intervals  {chronic  or  intermittent  volvulus) . 

Volvulus  of  the  small  intestine  may  affect  one  coil  or  the  entire 
ileum,  the  twist  usually  being  from  left  to  right.  Vomiting  occurs 
early,  and  sometimes  the  rounded  tympanitic  tumor  can  be  felt  in  the 
region  of  the  umbilicus. 

Volvulus  of  the  cecum  or  ascending  colon  may  occur  as  the  result 
of  congenital  malposition,  or  when  these  structures  possess  a  long 
mesentery.  The  symptoms  are  not  so  severe  as  in  sigmoid  volvulus, 
and  the  rounded  tympanitic  tumor  may  be  found  in  the  right  iliac 
fossa. 


746  MANUAL    OF    SURGERY 

The  treatment  of  \-()lvulus  is  to  untwist  the  loop  of  intestine. 
In  some  cases  it  may  be  necessary  to  evacuate  the  affected  coil  of 
bowel  by  puncture  before  this  can  be  accomplished,  the  puncture 
being  subsequently  closed  with  a  purse-string  suture.  If  the  gut  is 
viable  it  may  be  replaced  in  the  abdomen.  Shortening  of  the  mesen- 
tery or  fixation  of  the  bowel  to  the  abdominal  wall  has  been  suggested 
to  prevent  recurrence,  but,  in  the  sigmoid  at  least,  return  of  the 
trouble  can  be  surely  averted  only  by  resection  of  the  affected  loop. 
If  the  bowel  is  gangrenous  it  must  be  resected,  or  if  the  patient's 
condition  forbids  this,  brought  out  of  the  abdominal  wound  and  an 
artificial  anus  established.     Chronic  volvulus  is  treated  by  resection. 

Extraintestinal  tumors,  cysts,  and  abscesses  may  compress  the 
bowel,  as  may  also  viscera  other  than  the  intestine,  e.g.,  a  pregnant 
or  retroeverted  uterus,  a  floating  kidney  or  spleen.  Compression  b}- 
the  superior  mesenteric  vessels  is  described  under  ''Acute  Dilatation 
of  the  Stomach."  The  rectum  or  the  sigmoid  is  affected  in  over 
half  of  the  cases,  not  only  because  of  the  frequency  of  pelvic  tumors, 
but  also  because  a  tumor  in  this  region  cannot  expand  without 
encroaching  on  the  bowel,  owing  to  the  unyielding  nature  of  the 
pelvic  ring.  The  possibility  of  obstruction  from  the  pressure  of  a 
gauze  pack  or  a  drainage  tube  should  be  kept  in  mind.  The  symp- 
toms may  be  acute  or  chronic,  usually  the  latter.  The  treatment 
is  that  of  the  causative  lesion. 

Stricture  of  the  intestine  may  be  congenital  (see  congenital 
stenosis  of  the  intestine)  or  acquired  (cicatricial,  neoplastic,  spas- 
modic) . 

Cicatricial  strictiu'e  is  caused  by  the  repair  of  ulcers  due  to  tuber- 
culosis, syphilis,  dysentery,  pressure  (e.g.,  from  foreign  bodies,  con- 
striction in  strangulated  hernia),  rarely  typhoid,  as  the  ulcers  in  this 
disease  are  longitudinal;  by  the  repair  of  wounds  due  to  partial  rup- 
ture from  contusion,  or  due  to  extensive  lacerations,  perforations,  or 
intestinal  anastomosis,  especially  when  too  much  bowel  is  inverted  by 
the  surgeon;  and  by  the  repair  of  areas  of  inflammation,  e.g.,  due  to 
diverticulitis  or  pelvic  cellulitis.  Cicatricial  stricture  of  the  small 
intestine  is  usually  caused  by  tuberculosis,  that  of  the  colon  by  dysen- 
tery, that  of  the  rectum  by  syphilis  or  pelvic  cellulitis  (see  "Rec- 
tum"). 

Neoplastic  stricture,  in  95  per  cent,  of  the  cases,  is  due  to  car- 
cinoma of  the  colon,  which  affects  the  different  parts  in  the  following 
order  of  frequency:  sigmoid,  cecum,  ascending  colon,  transverse 
colon,  splenic  flexure,  hepatic  flexure,  descending  colon.  This  com- 
putation does  not  include  carcinoma  of  the  rectum,  which  is  classed 


ABDOMEN  747 

with  the  diseases  of  the  rectum.  Carcinoma  of  the  colon  is  cylin- 
drical-celled, and  may  jiroject  into  the  lumen  of  the  bowel  like  a 
cauliflower,  or,  more  frequently,  spread  around  the  lumen  and  pro- 
duce an  annular  stricture.  It  infiltrates  contiguous  coils  of  bowel  or 
other  viscera,  and  sometimes  ulcerates  into  them,  forming  an  internal 
fistula.  In  the  later  stages  the  growth  may  diffuse  itself  over  the 
peritoneal  cavity  (see  "Malignant  Disease  of  the  Peritoneum'') 
or  metastasize  to  the  liver,  lymph  glands,  or  lungs.  Metastasis, 
however,  is  often  postponed  for  a  much  longer  period  than  in  car- 
cinoma elsewhere.  Carcinoma  of  the  small  intestine  is  rare,  and 
usually  involves  the  duodenum  or  the  lower  ileum.  Sarcoma  is 
still  less  frequent,  both  in  the  small  and  in  the  large  bowel,  but 
occurs  more  often  in  the  former  than  in  the  latter,  and  is  more 
often  secondary  than  primary,  the  intestinal  mucosa  being  a  favorite 
site  for  metastases  in  lymphosarcoma  and  melanosarcoma.  Mention 
should  be  made  also  of  leukemic  tumors,  which  occur  in  leukemia  and 
pseudoleukemia,  and  which,  although  not  producing  obstruction, 
may,  because  of  ulceration  and  hemorrhage,  lead  to  an  erroneous 
diagnosis.  Benign  tumors  are  generally  polypoid  in  nature,  and 
cause  obturation,  hence,  following  the  classification  we  have  adopted, 
will  be  described  after  foreign  bodies  and  fecal  impaction. 

The  symptoms  of  cicatricial  and  malignant  stricture  are  at  first 
those  of  chronic  obstruction,  and  a  tumor  of  the  intestine  is  seldom 
suspected  unless  it  interferes  with  the  fecal  current.  Owing  to  the 
liquid  character  of  the  contents  of  the  small  bowel,  its  lumen  may 
suffer  almost  total  obliteration  before  the  onset  of  obstructive 
symptoms.  In  stricture  of  the  lower  colon  the  stools  may  be  de- 
formed or  diminished  in  caliber,  and  sometimes  the  stricture  can  be 
seen  with  the  sigmoidoscope.  After  giving  barium  by  mouth  or 
rectum  the  stricture  may  show  in  a  skiagram;  with  the  fluoroscope 
the  progress  of  the  barium  along  the  intestine  can  be  kept  under 
continuous  observation.  In  cicatricial  stricture  the  small  bowel  is 
more  often  involved  (60  per  cent.),  and  a  history  of  one  of  the  causes 
mentioned  above  may  be  obtained.  In  carcinoma  blood,  mucus,  and 
occasionally  fragments  of  the  growth  may  be  found  in  the  stools;  the 
tumor  can  be  felt  in  40  per  cent,  of  the  cases;  the  patient  is  usually 
over  40,  but  it  should  be  recalled  that  before  30  carcinoma  is  more 
frequent  in  the  colon  than  in  other-situations,  and  that  cachexia  is 
often  absent  until  the  growth  diffuses  itself  over  the  abdominal 
cavity.  Sarcoma  of  the  lymphatic  variety  may  extend  in  a  longi- 
tudinal direction  instead  of  around  the  bowel,  and  produce  dilatation 
rather  than  stricture,  hence  the  disease  occasionally  progresses  to  a 


748  MANUAL    OF    SURGERY 

fatal  termination  without  causing  obstruction,  especially  in  the  small 
intestine,  whose  contents  are  liquid.  Because  it  is  spread  out  along 
a  dilated  segment  of  intestine,  the  tumor  sometimes  exhibits  peristal- 
tic movements  and  may  crepitate  on  pressure.  As  many  of  these 
growths  are  metastatic  one  should  search  carefully  for  a  primary 
tumor  in  other  parts  of  the  body  before  deciding  on  operation. 

The  treatment  of  the  forms  of  stricture  mentioned  above  is 
enterectomy,  with,  if  the  disease  be  malignant,  a  V-shaped  portion  of 
the  mesentery  and  the  lymph  glands.  In  urgent  cases  an  artificial 
anus  should  be  established  and  the  resection  performed  at  a  later  date 
(see  "Colectomy")-  When  the  growth  is  irremovable  the  intestine 
above  and  below  may  be  united  by  lateral  anastomosis,  or  the  affected 
segment  side-tracked  as  described  under  "Intestinal  Exclusion." 

Spasmodic  stricttire  {enterospasm,  dynamic  obstruction)  is  due  to 
tetanic  contraction  of  a  segment  of  intestine.  It  may  be  caused  by 
lead  poisoning,  irritating  intestinal  contents,  hysteria  (see  "Phantom 
Tumor"),  and  trauma,  hence  occasionally  follows  abdominal  opera- 
tions. It  is  the  first  step  in  the  development  of  many  cases  of 
intussusception.  The  symptoms  may  be  those  of  acute  or  subacute 
obstruction;  sometimes  the  contracted  segment  of  bowel  can  be 
be  felt.  The  treatment  is  directed  to  the  cause;  heat  to  the  abdomen 
and  large  doses  of  atropin  are  of  value  in  relaxing  the  spasm. 

Foreign  bodies,  including  gall-stones  and  enteroliths,  rarely  cause 
obstruction.  Foreign  bodies  may  be  swallowed  accidentally,  e.g., 
artificial  teeth,  or  intentionally  by  children,  lunatics,  hysterical 
women,  and  showmen.  The  body  may  lodge  in  the  esophagus, 
stomach  (see  "Esophagus  and  Stomach"),  or  intestine,  and  cause 
obstruction  or  perforation,  but,  as  a  rule,  if  it  passes  through  the 
esophagus  the  rest  of  its  journey  along  the  alimentary  canal  is 
uneventful.  Foreign  bodies  that  have  been  left  in  the  peritoneal 
cavity,  e.g.,  forceps,  sponges,  etc.,  may  ulcerate  into  the  bowel. 
Enormous  snarls  of  intestinal  worms  sometimes  form  in  and  occlude 
the  intestine.  Gall-stones  of  sufficient  size  to  produce  obstruction 
must  enter  the  intestinal  tract,  usually  the  duodenum,  by  ulceration. 
Stones  even  of  large  size  passing  directly  into  the  hepatic  flexure 
rarely  block  the  colon.  Enteroliths  (intestinal  concretions)  are 
composed  of  phosphate  of  lime  and  hardened  feces,  often  with  some 
indigestible  material  as  a  nucleus;  of  masses  of  vegetable  residue, 
e.g.,  oatmeal  husks,  with  calcareous  salts  (avenoliths) ;  or  of  medicinal 
substances,  e.g.,  bismuth,  magnesia,  salol. 

The  symptoms  of  obstruction  from  foreign  bodies  are  generally  of 
a  subacute  nature.     The  diagnosis  may  be  possible  if  a  clear  history 


.\BDOMEN  749 

is  obtained,  if  the  foreign  body  can  be  felt,  and  if  it  can  be  seen  with 
the  X-ray.  The  seat  of  impaction  is  usually  the  lower  ileum,  since 
this  is  the  narrowest  portion  of  the  bowel.  Gall-stone  ileus  seldom 
occurs  before  fifty. 

The  treatment  is  removal  of  the  foreign  body  by  enterotomy, 
after  displacing  it  ui)wards  to  a  more  healthy  portion  of  the  bowel. 
If  the  bowel  is  gangrenous  or  badly  ulcerated  it  should  be  resected 
or  isolated  extraperitoneally. 

Fecal  impaction  is  most  common  in  old  ladies  with  chronic  con- 
stipation. The  masses  may  be  semisolid  or  as  hard  as  stone,  are 
generally  coated  with  mucus,  and  often  produce  ulcers  by  pressure 
(stercoral  ulcers),  which  ulcers  occasionally  perforate.  Fecal  impac- 
tion is  most  frequent  in  the  sigmoid  and  rectum,  but  in  some  cases  the 
mass  fills  the  entire  colon,  which  is  dilated,  elongated,  hypertrophied, 
and  prolapsed. 

The  symptoms  are  those  of  chronic  constipation  merging  into 
chronic  and  finally  into  subacute  obstruction.  The  fecal  masses  can 
be  felt  along  the  course  of  the  colon  or  in  the  rectum,  sometimes 
moved  from  one  portion  of  the  bowel  to  another,  and  can  be  seen  on 
X-ray  examination.  Pitting  on  pressure,  a  characteristic  sign  of 
ordinary  feces  in  the  colon,  is  often  absent.  The  stercoral  ulcers 
may  betray  themselves  by  fever,  tenderness  on  pressure,  and  a  muco- 
purulent sanious  discharge  from  the  rectum.  The  last  is  often 
associated  with  tenesmus. 

The  treatment  is  copious  enemata,  massage,  and  laxatives. 
When  situated  in  the  rectum  the  mass  may  be  broken  up  with  the 
finger.  Purgatives  and  massage  are  contraindicated  if  the  bowel  is 
inflamed.  The  prognosis  is  good,  although  death  may  occur  from 
associated  diseases,  toxemia,  or  perforation. 

Benign  intestinal  timiors  (fibroma,  myxoma,  lipoma,  adenoma) 
usually  project  into  the  lumen  of  the  gut  as  polyps,  are  often  multiple, 
and  seldom  cause  obstruction  unless  there  is  a  kink  in  the  bowel  or 
unless  they  induce  an  intussusception.  If  the  polyps  ulcerate, 
blood,  mucus,  and  pus  may  appear  in  the  stools.  Tenesmus  occurs 
when  the  growths  are  in  the  lower  bowel,  in  which  situation  they  may 
be  detected  with  the  finger  or  the  sigmoidoscope,  and  from  which 
situation  they  can  be  removed  through  the  anus  (see  "Polypus 
Recti")-  Isolated  poh-pi  causing"  obstruction  and  not  accessible 
through  the  anus  must  be  excised  after  enterotomy.  Multiple 
adenomata  of  the  colon  generally  occur  in  young  adults  and  show  a 
decided  tendency  to  malignant  degeneration;  the  only  remedy  for 
this  condition  is  excision  of  the  colon. 


750 


M.ANUAL    OF    SURGERY 


Intussusception  is  the  telescoping  of  one  part  of  the  intestine  into 
the  segment  below.  The  swallowed  portion  is  called  the  intussus- 
ceptum,  the  swallowing  segment  the  intussuscipiens  (Fig.  426).  The 
cause  is  irregular  peristalsis,  sometimes  induced  by  worms,  diarrhea, 
pohq^oid  tumors,  or  other  form  of  irritation.  The  author  has  had 
two  cases  of  traumatic  origin.  As  the  peritoneal  surfaces  of  the 
entering  and  returning  layers  of  the  intussusceptum  tend  to  adhere, 
and  the  mucous  surface  of  the  returning  layer  readily  slips  over  the 
mucous  surface  of  the  intussuscipiens,  the  intussusception  elongates 
at  the  expense  of  the  intussuscipiens  and  the  apex  is  always  repre- 
sented by  the  same  piece  of  bowel.  The  intussusception  is  not 
straight  as  in  the  diagram,  but  curved  like  a  sausage,  with  the  apex 
directed  towards  the  mesenteric  border.  This  crescentic  arrange- 
ment is  due  to  the  unyielding  nature  of  the  mesentery.  The  mesen- 
tery is  drawn  down  between  the  layers  of  the  intussusceptum,  hence 


B  C         D         E 


Fig.  426. — Diagram  of  intussusception.  A.  Apex.  B.  Neck.  C.  Entering  layer 
and  D.  returning  layer  of  intussusceptum.  R.  Intussuscipiens.  F.  Peritoneum. 
G.  Muscularis.     H.  Alucosa. 


is  Stretched,  bunched,  and  constricted.  The  circulation  is  further 
impeded  by  inflammatory  exudation,  and  this  leads  to  desquamation 
of  the  mucous  membrane  (hence  blood  and  shreds  in  the  stools) ,  and 
finally  to  strangulation  and  gangrene.  Intussusception  is  respon- 
sible for  39  per  cent,  of  the  cases  of  intestinal  obstruction.  The 
anatomical  varieties,  in  the  order  of  their  frequency,  are  the  ileocecal 
(44  per  cent.),  in  which  the  ileocecal  valve  and  ileum  pass  into  the 
colon,  the  enteric  (30  per  cent.),  usually  involving  the  jejunum,  the 
colic  (18  per  cent.),  involving  the  colon  alone,  and  the  ileocolic  (8 
per  cent.),  in  which  the  ileum  passes  through  the  ileocecal  valve. 
Multiple  retrograde  intussusceptions  sometimes  occur  in  the  dying, 
probably  from  rigor  mortis.  Double  intussusception,  in  which  an 
intussusception  slips  into  the  gut  below,  and  triple  intussusception, 
in  which  a  double  intussusception  slips  into  the  gut  below,  are 
extremely  rare. 


ABDOMEN  7  5  I 

Clinically  two  forms  must  be  distinguished,  the  acute,  which  is 
the  usual  variety,  and  the  chronic. 

The  symptoms  of  acute  intussusception  are  often  so  typical 
that  no  difficulty  is  experienced  in  distinguishing  the  condition 
from  other  forms  of  acute  obstruction.  Acute  intussusception  is 
most  frequent  in  male  infants  and  sometimes  follows  a  straining 
diarrhea.  Distension  is  not  so  marked  and  stercoraceous  vomiting 
not  so  common  as  in  most  other  forms  of  acute  obstruction.  Tenes- 
mus, with  the  passage  of  small  quantities  of  blood  and  mucus,  is 
more  severe  and  frequent  the  nearer  the  intussusception  is  to  the 
anus,  the  passages  becoming  particularly  offensive  when  the  intussus- 
ceptum  sloughs.  The  sausage-shaped  tumor,  concave  tow^ards  the 
umbilicus,  can  often  be  felt  in  the  course  of  the  transverse  or  the 
descending  colon.  The  tumor  becomes  harder  and  more  prominent 
with  each  recurrence  of  the  griping  pain,  and  progresses  slowly  towards 
the  anus,  which  may  be  relaxed,  and  through  which  the  apex  of  the 
intussusceptum,  feeling  like  a  soft  os  uteri,  may  be  palpated.  The 
right  iliac  fossa  may  feel  empty,  the  bowel  in  this  region  haxing 
passed  along  the  colon.  Without  treatment  death  usually  takes 
place  in  from  one  to  eight  days. 

The  symptoms  of  chronic  intussusception  are  not  so  typical  as 
those  of  the  acute  variety.  The  condition  is  most  common  in  men 
between  twenty  and  forty,  is  often  due  to  the  dragging  of  a  pol>p. 
and  may  last  for  a  number  of  months  or  even  a  year.  There  are 
attacks  of  pain,  vomiting,  and  diarrhea,  often  with  tenesmus  and  the 
passage  of  blood  and  mucus.  The  tumor  can  be  felt  through  the 
abdomen  in  half  of  the  cases,  and  by  rectum  in  one-third;  sometimes 
it  disappears  between  the  attacks.  Visible  peristalis  and  other 
signs  of  chronic  obstruction  are  in  evidence.  Death  occurs  in  about 
95  per  cent,  of  the  cases,  from  acute  obstruction,  peritonitis,  or 
hemorrhage.  In  about  one-fourth  of  the  cases  the  intussusceptum 
sloughs  and  is  passed  by  the  bowel,  but  only  a  very  few^  of  these 
terminate  in  recovery. 

The  treatment  of  acute  intussusception  by  the  administration  of 
opium  and  belladonna,  and  the  injection  of  air  or  water  into  the 
rectum  should  be  discarded.  It  wastes  valuable  time,  is  uncertain, 
necessitates  anesthesia,  and  may  rupture  the  bow^el,  hence  is  more 
dangerous  than  laparotomy.  The  abdomen  should  be  opened,  as 
early  as  possible,  in  the  median  line,  and  the  intussusception  reduced, 
not  by  traction,  which  may  tear  the  bowel,  but  by  milking  or  pressing 
the  Intussusceptum  upwards.  It  has  been  suggested,  in  order  to 
prevent  recurrence,  to  shorten  the   mesentery  or  suture  it  to  the 


752  MANUAL    OF    SURGERY 

ascending  mesocolon,  or  to  fix  the  bowel  to  the  abdominal  wall. 
When  reduction  is  impossible,  i.e.,  in  half  of  the  cases,  and  in  almost 
all  of  the  cases  after  the  second  or  the  third  day,  the  procedure  to  be 
adopted  depends  on  the  condition  of  the  bowel  and  of  the  patient. 
When  the  intussusceptum  is  gangrenous  it  must  be  resected  (see 
"Maunsell's  Method"),  the  ends  of  the  bowel  being  anastomosed  if 
the  general  condition  of  the  patient  is  good,  or  sutured  in  the  wound, 
thus  forming  an  artificial  anus,  if,  as  is  usual,  the  condition  of  the 
patient  is  poor.  Resection  of  the  entire  intussusception  is  indicated 
only  when  the  intussuscipiens  is  gangrenous.  When  the  bowel  is 
irreducible  and  in  good  condition  a  lateral  anastomosis  may  be  made 
between  the  intestine  above  and  below  the  intussusception.  In 
children  the  mortality  is  between  30  and  40  per  cent,  when  reduction 
is  easy,  and  over  90  per  cent,  when  reduction  is  impossible.  In 
chronic  intussusception  in  adults  the  best  treatment,  as  a  rule,  is 
resection,  whether  the  intussusception  is  reducible  or  not,  because  the 
condition  is  often  caused  by  a  tumor  actually  or  potentially  malignant. 
The  mortality  in  these  cases  is  not  so  high  as  in  acute  intussusception. 
Intestinal  paralysis,  adynamic  ileus,  or  pseudoobstruction,  may 
occur  with  or  without  gastric  paralysis  (see  "Acute  Dilatation  of  the 
Stomach") ;  in  the  former  event  the  term  gastrointestinal  paralysis  is 
applicable.  Intestinal  paralysis  may  be  mechanical,  reflex,  or  toxic 
in  origin,  but  in  most  instances  two  of  these  factors  are  present.  It 
is  most  frequently  caused  by  peritonitis,  but  occurs  also  in  enteritis, 
acute  pancreatitis,  thrombosis  or  embolism  of  the  mesenteric  vessels, 
biliary  and  renal  colic,  strangulation  of  the  omentum,  diseases  of  the 
bladder,  prostate,  and  seminal  vesicles,  diseases  and  injuries  of  the 
testicle,  ovary,  and  central  nervous  system,  and  as  a  terminal  event 
in  other  maladies,  particularly  those  accompanied  by  delirium  or 
coma.  Fracture  of  the  spine,  uremia,  and  pneumonia  should  receive 
special  mention.  That  form  occurring  after  abdominal  section,  not 
due  to  peritonitis,  is  caused  by  the  sudden  relief  of  chronic  pressure 
(e.g.,  the  removal  of  a  large  tumor)  or  by  undue  handling  of  the 
intestines.  The  symptoms  are  almost  identical  with  those  of  acute 
obstruction.  There  may,  however,  be  evidences  of  the  causative 
lesion,  and  peristalsis  is  absent.  In  intestinal  obstruction  increased 
peristalsis  is  a  cardinal  sign  which  is  absent  only  in  the  final  stage, 
when  paralysis  ensues.  Rectal  ballooning,  which  is  sometimes  de- 
scribed as  a  sign  of  appendicitis,  obstruction  of  the  bowel,  etc.,  is 
really  an  indication  of  intestinal  paralysis  from  any  cause.  The 
treatment  is  that  of  the  cause.  In  addition  the  stomach  may  be 
washed  out,  a  tube  passed  into  the  colon,  enemata  administered,  and 


ABDOMEN  753 

strychnin,  cscrin,  pituitarin,  atropin  given  hypodermatically.  Intes- 
tinal paralysis  of  severe  degree  is  generally  fatal.  An  artificial  anus 
may  be  established,  but  usually  does  not  drain  more  than  the  coil 
in  which  it  is  made. 

OPERATIONS  ON  THE  INTESTINES 

Intestinal  Localization. — The  large  intestine  is  differentiated  from 
,  the  small  intestine  by  its  mesenteric  attachment,  greater  size,  longi- 
tudinal bands,  sacculations,  and  by  its  appendices  epiploicae.  The 
method  for  finding  the  upper  end  of  the  jejunum  is  given  under 
''Gastroenterostomy."  In  order  to  determine  the  situation  and 
direction  of  a  loop  of  intestine,  the  following  facts,  according  to 
Monks,  are  of  great  value:  The  average  length  of  the  small  intestine 
is  twenty-one  feet.  The  upper  third  occupies  the  left  hypochon- 
drium  (duodenum  excluded) ;  the  middle  third,  the  middle  section  of 
the  abdomen;  the  lower  third,  the  pelvic  and  right  iliac  regions.  The 
intestine,  from  above  downwards,  decreases  in  size  and  thickness, 
becomes  less  opaque,  has  smaller  vessels,  which  are  nearer  together, 
and  changes  in  color  from  bright  pink  or  red  to  pinkish  or  yellowish 
gray.  In  the  upper  jejunum  large  and  numerous  valvulse  conni- 
ventes  may  be  felt,  but  are  imperceptible  beyond  the  fourteenth  to 
the  sixteenth  foot.  The  fixation  of  the  two  ends  of  the  intestine 
may  be  palpated;  and  the  consistency  of  the  contents  increases  from 
above  downwards.  The  mesentery  is  thin  and  transparent  at  the 
upper  part,  thick  and  opaque  in  the  lower  third.  The  lunettes  between 
the  vessels  can  be  seen  in  the  upper  eight  feet  or  more,  but  not  in  the 
lower  third.  Tabs  of  fat  extending  onto  the  intestine  begin  to 
appear  at  about  the  fourteenth  foot  and  become  more  and  more 
prominent.  In  the  upper  third  the  mesenteric  vessels  are  large  and 
far  apart,  form  primary  loops  as  far  as  the  fourth  foot  when  second- 
ary loops  appear,  and  give  off  long,  regular,  unbranching  vasa  recta 
to  the  intestine.  In  the  lower  third  the  mesenteric  vessels  are  small 
and  close  together,  have  many  loops  often  obscured  by  fat,  and  give 
oft"  small,  short,  and  irregular  vasa  recta.  The  root  of  the  mesentery 
is  to  the  left  of  the  median  line  above,  to  the  right  below.  If  a  loop 
of  bowel  is  placed  parallel  with  the  root  of  the  mesentery,  the  upper 
end  will  be  nearer  the  duodenum,  providing  there  is  no  twist  in  the 
mesentery. 

Enterotomy  signifies  an  incision  into  the  intestine  for  the  purpose 
of  removing  a  foreign  body  or  for  exploration.  After  guarding 
against    fecal   extravasation    (see    "Enterectomy")    a   longitudinal 

48 


754 


MANUAL    OF    SURGERY 


incision  is  made  opposite  the  mesentery,  and  tlie  wound  closed  by 
enterorrhaphy. 

Enterorrhaphy,  or  suture  of  the  intestine,  is  performed  with  at 
least  tw^o  rows  of  sutures.  The  inner  row  should  be  of  catgut,  and 
perforate  all  the  coats  of  the  bowel  in  order  to  secure  firm  apposition 
and  control  bleeding.  The  suture  may  be  interrupted  or  continuous, 
over  and  over  or  mattress,  tied  externally  or  within  the  bowel.  In 
enterorrhaphy  a  long  continuous  suture  of  any  variety  should,  to 
prevent  puckering,  be  knotted  or  locked  at  intervals.  The  outer 
row  is  of  fine  silk  or  celluloid  thread,  introduced  with  a  fine  straight 
round  needle.  It  is  essential  that  the  wound  be  air-tight,  and  that 
the  edges  be  inverted  so  that  serous  membrane  shall  come  in  contact 
with   serous  membrane.     The  Lembert  suture  is  placed   at  right 


10      11 


Fig.  427. — Intestinal  sutures. 

I.  Wolfler.  2.  Czerney-Lembert.  3.  Lembert  interrupted.  4.  Lembert-Dupytren  continuous. 
S.  Gushing  continuous  mattress.  6.  End  to  end  intestinal  anastomosis.  7.  Lembert  purse  string. 
8.  Halstead  mattress,  interrupted.     9.  Gely.     10.  Gussenbauer.     11.  Connell. 


angles  to  the  wound.  The  needle  is  inserted  about  one-fourth  inch 
from  the  edge  of  the  wound,  goes  down  to  and  through  the  submucous 
coat  but  not  through  the  mucous  membrane,  is  brought  out  one- 
eighth  inch  from  the  edge  of  the  wound,  and  in  a  similar  manner  on 
the  opposite  side,  so  that  when  tied  the  edges  of  the  wound 
are  inverted.  The  stitches  are  about  one-eighth  of  an  inch  apart. 
All  other  seroserous  sutures  are  inserted  with  the  precautions  used 
in  employing  the  Lembert  suture.     (Fig.  427-3.) 

Enterostomy  is  the  making  of  an  opening  into  the  intestine  in 
order  to  feed  a  patient  or  to  drain  away  the  contents  of  the  intestine 
(artificial  anus) ;  according  to  the  situation  of  the  opening  the  opera- 
tion is  called  duodenostomy,  jejunostomy,  ileostomy,  or  colostomy. 

Duodenostomy    or   jejunostomy   is   occasionally   performed  to 


ABDOMEN  755 

feed  the  ]')aticnt  in  s^astric  ulcer  or  cancer,  when  a  gastroenterostomy 
is  inappHcable;  only  jejunostomy  could  be  employed  if  the  ulcer  or 
growth  were  in  the  duodenum  or  the  upper  jejunum.  As  the  idea  is 
to  introduce  food  and  prevent  the  escape  of  intestinal  contents,  the 
principles  used  in  the  Witzel  or  the  Stamm-Kader  gastrostomy 
should  be  employed.  Complete  division  of  the  bowel,  with  suture 
of  the  upper  end  of  the  lower  segment  to  the  skin,  and  anastomosis 
of  the  upper  segment  with  the  side  of  the  lower  segment  is  a  much 
more  serious  operation  and  is  very  rarely  indicated. 

Ileostomy  may  be  demanded  in  cases  of  intestinal  obstruction, 
above  the  ileocecal  valve,  in  which  the  patient's  condition  is  so  bad 
that  search  for  or  removal  of  the  cause  of  the  obstruction  is  contrain- 
dicated.  The  operation  is  performed  in  the  same  manner  as  colos- 
tomy. If  the  patient  survives,  the  obstructing  lesion  and  the  artifi- 
cial anus  are  removed  at  a  second  operation,  or  the  obstruction  alone 
is  dealt  with  at  the  second  operation  and  the  continuity  of  the  ileum 
restored  at  a  third  operation.  Closure  of  the  artificial  anus,  how- 
ever, must  not  be  delayed  longer  than  is  absolutely  necessary,  be- 
cause of  its  interference  with  nutrition,  which  is  more  marked  the 
higher  the  opening,  and  because  of  the  digestive  effect  of  the  intestinal 
juices  on  the  skin. 

Colostomy,  or  colotomy,  as  it  is  sometimes  called,  is  commonly 
employed  for  the  relief  of  obstruction,  and  occasionally  for  the  pur- 
pose of  giving  the  large  bowel  rest  and  alowing  irrigation  in  cases  of 
chronic  dysentery  or  other  severe  ulcerative  lesions.  Irrigation  ot 
the  colon,  without  diversion  of  the  fecal  current,  is  best  performed 
through  the  appendix  (see  "Appendicostomy"),  or  when  this  is  not 
possible,  because  of  stricture  of  the  appendix,  through  a  valvular 
opening  in  the  cecum  [cecostomy) ,  which  is  made  in  the  same  way  as 
the  Stamm-Kader  gastrostomy,  but  which  in  this  region  is  called 
Gibson'' s  operation.  In  order  to  interfere  as  little  as  possible  with 
nutrition,  an  artificial  anus  should  be  made  as  low  in  the  colon  as 
the  condition  for  which  it  is  done  permits.  Hence  when  sigmoidos- 
iomy  is  contraindicated,  because  of  obstruction  in  the  descending 
colon,  the  opening  should  be  made  in  the  transverse  colon,  and  not, 
as  is  customary,  in  the  cecum  or  the  ascending  colon.  Transversos- 
tomy,  in  addition  to  its  preserving  more  of  the  large  bowel  for  the 
purpose  of  nutrition  than  an  artificial  anus  in  the  right  inguinal 
region,  is,  owing  to  the  long  transverse  mesocolon,  easier  to  perform 
does  not  produce  so  much  irritation  of  the  skin,  and  is  easier  to 
close,  at  least  by  resection  and  anastomosis.  The  incision  is  made 
in  the  abdomen  above  the  umbilicus,  through  the  middle  line  or  the 


756 


MANUAL    OF    SURGERY 


left  rectus.  The  rest  of  the  operation  is  similar  to  inguinal  colos- 
tomy, which,  since  it  is  the  usual  procedure,  will  be  described  in  detail. 
Inguinal  colostomy  is  performed  through  an  incision,  two  or  three 
inches  long,  made  at  right  angles  to  a  line  drawn  from  the  anterior 
superior  spine  to  the  umbilicus,  its  middle  crossing  this  line  at  the 
junction  of  the  outer  and  middle  thirds.  A  loop  of  the  colon  is 
pulled  into  the  wound,  the  upper  limb  of  the  loop  being  made  taut  in 
order  to  prevent  subsequent  prolapse,  and  the  gut  fastened  by  passing 
a  glass  rod  through  the  mesentery  and  suturing  the  parietal  peri- 
toneum and  then  the  skin  to  the  bowel.  Instead  of  the  glass  rod, 
gauze  or  other  material  may  be  used,  or  the  middle  of  the  skin  incision 
may  be  united  beneath  the  bowel.     If.  owing  to  absence  or  extreme 


Fig.  428. — Immediate  enterostomy. 

brevity  of  the  mesocolon,  a  sufficiently  long  loop  cannot  be  obtained 
the  colon  should  be  mobilized  by  incising  the  peritoneum  on  the 
outer  side  of  the  gut  (see  "Colectomy").  The  bowel  is  opened 
transversely  with  scissors  or  cautery,  at  the  end  of  two  or  three  days, 
after  protecting  adhesions  have  formed;  no  anesthetic  is  required. 
The  gut  should  not  be  completel}'  divided,  however,  for  a  week  or 
ten  days,  otherwise  it  may  retract  within  the  abdomen.  When 
immediate  opening  of  the  intestine  is  mandatory,  there  is  consider- 
able risk  of  infecting  the  peritoneal  cavity  with  feces.  The  author 
prevents  this  in  the  following  manner :  The  loop  of  bowel  is  emptied 
by  pressure,  and  a  clamp  placed  at  each  extremity,  the  whole  being 
surrounded  by  gauze.  One-half  of  a  Murphy  button  is  inserted  into 
the  empty  loop  of  intestine  through  a  small  incision  and  the  other 
half  is  squeezed  into  the  end  of  a  long  rubber  tube  whose  calibre  is 


.\BDOMEN  757 

slightly  smaller  than  that  of  the  flange  of  the  button,  thus  making  a 
tight  joint  (Fig.  428).  The  two  halves  of  the  button  are  then  pressed 
together,  or  in  other  words  a  lateral  implantation  is  made  between 
the  rubber  tube  and  the  bowel.  The  feces  drain  through  the  rubber 
tube  into  a  receptacle  on  the  floor.  By  the  time  the  button  has 
sloughed  through  the  bowel,  i.e.,  at  the  end  of  two  or  three  days, 
adhesions  will  have  closed  the  peritoneal  cavity.  Often  the  bowels 
move  only  once  or  twice  a  day,  and  give  little  trouble.  If  desired, 
however,  a  rubber  "colostomy  bag"  may  be  worn,  or  the  artificial 
anus  may  be  closed  between  bowel  movements  by  a  hollow  rubber 
bulb,  shaped  somewhat  like  a  dumb-bell;  one  end  is  placed  in  the 
intestine  and  the  bulb  is  then  distended  with  air.  The  artificial  anus 
may  be  provided  with  a  more  or  less  satisfactory  sphincter  by  drawing 
the  bowel  through  the  split  rectus  muscle  or  through  a  McBurney 
incision. 

Bodine's  operation  facilitates  the  closure  of  the  artificial  anus. 
A  long  loop  of  bowel  is  drawn  from  the  abdomen,  and  the  two  limbs 
sutured  together  for  six  inches,  first  near  the  mesenteric  attachment 
and  again  near  the  anterior  longitudinal  band.  The  loop  is  then 
replaced  in  the  abdomen  except  for  its  end.  which  is  sutured  to 
the  abdominal  wall,  and  later  opened.  When  the  artificial  anus 
has  served  its  purpose,  the  long  spur  between  the  two  limbs  of  the 
loop  is  cut  through  with  a  heavy  clamp,  which  generally  takes  about 
one  week.  The  bowel  around  the  artificial  anus  is  then  separated 
as  far  as  the  peritoneum,  the  opening  closed  with  inversion  sutures, 
and  the  muscles  and  the  skin  drawn  together  over  the  suture  line. 

In  lumbar  colostomy  the  large  bowel  is  approached  extraperi- 
toneally  through  the  loin.  The  operation  has  been  abandoned, 
because,  as  compared  with  iliac  colostomy,  it  is  more  difficult,  does 
not  completely  divert  the  feces,  and  the  resulting  opening  is  not 
well  situated  for  cleanliness. 

Operative  closure  of  the  artificial  anus  will  be  required  in  those 
cases  in  which  the  condition  for  which  it  has  been  established  has 
been  removed.  The  manner  of  closure  after  Bodine's  operation  is 
described  above.  In  other  cases  the  opening  in  the  bowel  is  dis- 
infected with  carbolic  acid,  stuffed  with  gauze,  and  closed  with 
sutures.  The  environing  skin  is  then  sterilized,  and  the  abdomen 
opened  by  an  elliptical  incision  surrounding  the  anus,  the  involved 
segment  of  bowel  being  resected,  and  the  fecal  circulation  re- 
established by  an  end  to-end-anastomosis.  In  many  cases  the 
lower  segment  will  be  so  contracted  that  the  surgeon  will  prefer  a 
lateral  anastomosis. 


758  MANUAL    OF    SURGERY 

A  fecal  or  intestinal  fistula  differs  from  an  artificial  anus  in  that 
only  a  portion,  and  not  all,  of  the  intestinal  contents  escape  through 
the  abnormal  opening.  It  may  be  congenital  (see  "Umbilical 
Fistula")  or  follow  injury,  ulceration,  strangulation,  and  malignant 
tumors  of  the  bowel,  or  inflammatory  lesions  of  the  abdominal 
cavity  secondarily  involving  the  bowel.  Occasionally  a  fecal 
fistula  is  deliberately  established  by  the  surgeon.  External  fistula 
i.e.,  opening  on  the  skin,  may  proceed  from  any  portion  of  the 
intestinal  canal.  The  discharge  from  the  duodenum  or  the  upper 
jejunum  is  fluid,  acid,  intensely  irritating  to  the  skin,  and  contains 
bile  and  undigested  food;  that  from  the  lower  ileum  or  the  cecum  is 
neutral  or  alkaline,  much  less  irritating  and  contains  less  undigested 
food;  that  from  the  lower  colon  is  semisolid  or  solid  fecal  matter. 
If  there  is  any  doubt  as  to  whether  the  bowel  is  open  or  not,  e.g., 
after  some  operations  for  appendiceal  abscess  in  which  the  dis- 
charge is  very  foul,  methylene  blue  may  be  given  by  mouth;  if  there 
is  an  intestinal  fistula  the  discharge  will  become  blue,  the  earlier 
the  higher  the  fistula  in  the  bowel.  A  high  intestinal  fistula  dis- 
charges very  quickly  anything  that  is  taken  into  the  stomach,  thus 
producing  rapid  emaciation  and  death.  When  of  large  size,  an 
external  fecal  fistula  requires  the  same  treatment  as  artificial  anus. 
Smaller  fistulae,  particularly  in  the  large  bowel,  often  close  spon- 
taneously. If  the  tract  is  lined  by  mucous  membrane,  this  should 
be  destroyed  with  the  cautery.  When  opening  into  the  small  bowel 
even  minute  fistulae  sometimes  refuse  to  heal.  In  these  cases  the 
external  opening  should  be  treated  as  mentioned  above  for  artificial 
anus,  the  tract  dissected  out,  and  the  opening  in  the  bowel  closed 
with  sutures.  When  these  methods  are  inapphcable  or  inadvisable, 
exclusion  of  the  intestine,  which  is  described  on  a  latter  page,  may 
be  performed.  An  internal  fistula  between  the  stomach  and  the 
colon  causes  rapid  emaciation,  the  appearance  of  undigested  food 
in  the  stools,  and  of  fecal  mattei  in  the  vomit  us,  between  the  intes- 
tine and  the  bladder,  fecal  matter  in  the  urine  and  infection  of  the 
urinary  tract.  If  the  condition  is  not  due  to  inoperable  tuber- 
culosis or  carcinoma  the  viscera  should  be  separated  and  the  opening 
in  each  closed. 

Enterectomy,  or  resection  of  the  intestine,  is  performed  for  many 
conditions,  of  which  the  following  are  the  most  important:  gangrene, 
extensive  injury,  tumors,  artificial  anus,  cicatricial  stenosis,  tuber- 
culosis, and  injury  to  the  vessels  supplying  the  segment  of  bowel. 
The  portion  of  gut  to  be  removed  is  drawn  from  the  body,  and  the 
peritoneal  cavity  protected  by  gauze  packing.     The  loop  is  emptied 


ABDOMEN  75Q 

by  stripping  with  the  finger,  and  rubber-coated  clamps  placed  on 
the  bowel  on  each  side  of  the  proposed  incisions,  i.e.,  four  clamps 
are  used.  In  the  absence  of  intestinal  clamps,  gauze  or  rubber 
tubing  may  be  tied  around  the  bowel.  The  mesentery  is  then 
ligated  in  sections,  a  short  distance  from  the  bowel,  and  divided;  in 
maUgnant  disease  particularly,  a  V-shaped  portion  of  the  mesentery 
is  removed,  great  care  being  exercised  not  to  cut  oE  the  blood  supply 
of  the  bowel  which  is  to  remain.  The  bowel  is  divided  somewhat 
obliquely,  removing  more  at  the  free  than  at  the  mesenteric  border, 
in  order  to  give  a  greater  circumference,  and  to  assure  a  good  blood 
supply  to  the  antimesenteric  portion.  The  continuity  of  the 
intestine  is  re-established  by  circular  enterorrhaphy,  lateral  anasto- 
mosis, or  lateral  implantation  (vide  infra).  The  opening  in  the 
mesentery  is  closed,  and  any  excess  folded  and  held  in  place  by 
sutures. 

Colectomy,  or  removal  of  a  part  or  the  whole  of  the  colon, 
requires  special  consideration,  because  of  the  arrangement  of  the 
peritoneum  around  the  large  bowel.  The  middle  of  the  sigmoid 
and  the  transverse  colon  can  generally  be  withdrawn  from  the 
abdomen,  resected  like  the  small  intestine,  and  anastomosed  by 
circular  enterorrhaphy.  Unlike  the  small  intestine,  however,  the 
transverse  colon  has  attached  to  it  three  peritoneal  shelves  that 
must  be  dealt  with,  the  gastrocolic  omentum,  the  greater  omentum, 
and  the  mesocolon,  the  last  containing  the  blood  supply.  The 
ascending  and  the  descending  colon  are,  as  a  rule,  only  partly  covered 
with  peritoneum,  and  are  fixed  to  the  posterior  abdominal  wall. 
Thanks  to  the  arrangement  of  the  vascular  supply,  however,  which 
approaches  the  bowel  from  the  mesial  side,  these  portions  of  the 
colon  can  be  completely  mobilized,  and  brought  to  a  safe  place  out- 
side the  abdomen  for  operative  attack,  by  incising  the  peritoneum 
to  the  outer  side  of  the  gut,  bluntly  separating  the  loose  cellular 
tissue  over  the  kidney  and  the  ureter,  and  displacing  the  gut  toward 
the  median  line.  On  the  left  side  the  splenic  flexure  can  be  liberated 
by  cutting  the  phrenocolic  hgament.  Thus,  if  necessary,  the  entire 
colon  can  be  exteriorized,  almost  bloodlessly,  through  a  median 
incision.  After  mobihzation  the  affected  segment  can  be  resected 
with  as  little  difficulty  as  a  piece  of  small  intestine,  and  the  con- 
tinuity of  the  bowel  re-established  by  one  of  the  methods  described 
below.  Lateral  anastomosis,  however,  is  to  be  preferred  in  the 
ascending  and  the  descending  colon,  because  of  the  incomplete 
peritoneal  investment;  if  circular  enterorrhaphy  is  performed  in 
these  parts  of  the  large  bowel,  the  anastomosis  should  be  isolated 


760  MANUAL   OF    SURGERY 

from  the  general  peritoneal  cavity  by  vaselinized  gauze,  as  leakage 
not  infrequently  follows.  Primary  resection  of  a  portion  of  the 
colon,  unless  the  bowels  have  been  thoroughly  evacuated  previously, 
is  so  dangerous  (^mortality  30  to  40  per  cent.)  that  in  all  cases  of 
obstruction  the  patient  should  be  operated  upon  in  two  or  more 
stages(  mortality  10  per  cent.);  this  statement  appHes  particularly 
to  cases  of  malignant  disease  of  the  colon.  At  the  first  operation 
the  chief  indication  is  to  relieve  the  fecal  stasis,  by  the  formation 
of  an  artificial  anus.  At  a  later  period  the  growth  is  removed  and, 
if  possible,  the  artificial  anus  closed;  or  the  work  may  be  done  in 
three  stages,  by  separating  the  excision  of  the  growth  and  the 
closure  of  the  artificial  anus  by  an  interval.  Since  closure  of  the 
artificial  anus,  by  resection  and  anastomosis,  is  often  a  formidable 
undertaking,  perhaps  the  best  plan,  in  suitable  cases,  is  to  remedy 
the  mischief  in  four  stages,  (i)  The  loop  containing  the  growth 
is  mobilized,  the  growth  brought  out  of  the  abdomen,  and  the  limbs 
of  the  loop  sutured  together  and  fastened  to  the  abdoininal  wall 
as  in  Bodine's  colostomy.  A  rubber  tube  is  anastomosed,  as 
described  under  colostomy,  wdth  the  extraabdominal  portion  of 
the  bowel  above  the  growth.  (2)  When  the  tubes  comes  away  the 
growth  is  amputated.  (3)  At  the  end  of  a  week  the  spur  between 
the  limbs  of  the  loop  is  cut  through  with  a  clamp.  (4)  After  the 
clamp  has  done  its  work,  i.e.,  about  a  week,  the  artificial  anus  is 
closed,  as  after  the  Bodine  operation.  The  chief  objection  to  the 
proceeding  just  outlined  is  that  it  prohibits  extensive  removal  of 
the  lymph  channels  and  glands,  but,  according  to  Buthn,  over 
60  per  cent,  of  the  deaths  from  colonic  carcinoma  are  due  to  obstruc- 
tion, and  occur  before  metastasis  take  splace.  If  one  does  perform 
a  primary  resection  for  an  obstructing  growth  in  the  colon,  an 
artificial  anus  above  the  anastomosis  should  be  made  at  the  same 
time. 

End-to-end  anastomosis,  or  circular  enter orrhaphy,  may  be 
performed  by  simple  suturing  or  with  the  aid  of  special  apparatus. 
Simple  suturing  is  always  to  be  preferred.  The  best  plan  is  to 
bring  the  clamps  together  as  in  gastroenterostomy  (Fig.  403),  suture 
the  apposed  peritoneal  surfaces,  paying  special  attention  to  the 
mesenteric  border  as  described  below,  and  then  to  finish  the  opera- 
tion like  a  gastroenterostomy.  If  this  is  not  done  the  ends  of 
the  intestine  may  be  brought  together  with  two  sutures,  one  opposite 
the  other,  passing  through  the  w^alls  of  both  segments,  midway 
between  the  free  border  and  the  mesenteric  attachment.  These 
sutures  are  left  long  and  held  by  an  assistant,  in  order  to  act  as 


ABDOMEN 


761 


guides.  A  third  suture  is  inserted  at  the  mesenteric  border  (Figs. 
427-429),  so  as  to  obliterate  the  space  normally  present  between 
the  layers  of  the  mesentery  at  this  point.  The  two  segments  are 
now  united  by  a  continuous  suture  of  catgut,  passing  through  all 
the  coats  in  order  to  secure  firm  apposition  and  stop  bleeding. 
After  the  posterior  margins  have  been  united,  the  suture  may  be 
inserted   like  a  Gushing  right  angle  suture,  except  that  it  passes 


Fig.   429. — Mesenteric  stitch. 


Fig.  430. 


through  all  the  coats  (Fig.  430).  This  layer  of  sutures  is  buried 
by  a  continuous  Lembert  or  Gushing  suture  of  silk,  extending  around 
the  whole  circumference  of  the  anastomosis.  It  is  well  to  insert  an 
extra  suture  at  the  mesenteric  insertion  as  shown  in  (Fig.  431). 
Instead  of  dividing  the  bowel  obliquely  to  prevent  stenosis,  as  ex- 
plained under  '"Enterectomy,"  Mayo  incises  the  antimesenteric 
border  of  each  segment  in  the  axis  of  the  bowel  and  sutures  the 


timmmmii  imiim  h 


Fig.  431. 


Fig.  432. 


incisions  together  transversely,  as  in  the  Heineke- Mikulicz  pyloro- 
plasty. When  the  ends  of  the  bowel  are  of  unequal  size,  the  larger 
opening  may  be  partly  closed  by  sutures,  or  the  smaller  end  may 
be  cut  obliquely  and  the  larger  transversely;  under  these  circum- 
stances, however,  it  is  much  better  to  close  both  ends  and  perform 
a  lateral  anastomosis.  In  MaunseWs  operation  the  ends  of  the  gut 
are  first  united  by  two  sutures,  one  at  the  mesenteric  and  one  at  the 
free  border,  the  knots  being  placed  within  the  lumen  and  the  sutures 


762 


MANUAL    OF    SURGERY 


left  long.  A  longitudinal  incision  is  then  made  in  the  free  margin 
of  the  segment  of  bowel  with  the  larger  diameter,  about  an  inch 
from  its  end.  These  sutures  are  drawn  out  through  the  lateral 
opening  (Fig.  432)  and  by  traction  an  artificial  intussusception  is 
produced  (Fig.  433).  The  edges  of  the  protruded  intussusceptum 
are  united  by  sutures  passing  through  all  the  coats  of  the  bowel, 
the  intussusception  reduced,  and  the  longitudinal  opening  closed 
by  Lembert  sutures.  The  union  may  be  reinforced  by  an  extra 
layer  of  Lembert  sutures. 

Of  the  many  forms  of  special  apparatus  which  have  been  sug- 
gested to  facihtate  end-to-end  anastomosis,  the  Murphy  button 
alone  will  be  described,  although  it  too  is  almost  never  employed  at 
the  present  time.  The  button  consists  of  two  hollow,  flanged, 
metallic  cylinders.  When  one  cylinder  is  inserted  into  the  other 
and   pressed   home  the  flanges  cannot  be  separated  except  by  un- 


FiG.  433. — Maunsell's  operation. 


A       P  B~ 

Fig.     434. — Murphy   button. 

A,    Male    half;  B,  female  half. 

The  round  holes  are  for  drainage. 


screwing,  there  being  two  spring  catches  (S.S.  Fig.  434)  on  opposite 
sides  of  the  smaller  cylinder,  and  a  screw  thread  in  the  interior  of  the 
larger.  In  one-half  of  the  button  there  is  an  additional  flange 
(P.  Fig.  415)  separated  from  the  first  by  a  spring  C.  (Fig.  434)  which 
exercises  constant  pressure  on  the  bowel,  and  thus  induces  necrosis 
and  liberates  the  button,  the  segments  of  bowel  having  in  the 
meantime  united.  A  purse-string  suture  is  inserted  into  each  end 
of  the  divided  intestine,  special  attention  being  given  to  the  mesenteric 
insertion  so  that  it  will  be  included  within  the  grasp  of  the  button. 
One-half  of  the  button  is  inserted  into  the  open  end  of  each  segment 
of  bowel  and  the  purse-string  suture  drawn  tight  and  tied.  Any  excess 
of  mucous  membrane  is  cut  off  and  the  two  halves  of  the  button 
pressed  together.  The  button  should  be  passed  with  the  feces  in 
from  two  to  three  weeks.  The  disadvantages  of  the  button  are  that 
it  is  a  foreign  body  which  may  become  impacted  or  retained,  producing 
obstruction  or  ulceration  of   the  bowel,   and  that  its  use  may  be 


AUDOMKX  763 

followed  by  leakage,  the  result  of  a  spreading  of  the  necrosis  which 
it  necessarily  induces.  The  button  should  always  be  tried  before 
operation,  as  many  are  defective  in  construction. 

Lateral  anastomosis  is  performed  to  short  circuit  a  portion  of 
the  intestinal  canal  (Fig.  437)  and  sometimes  instead  of  end-to-end 
anastomosis  after  resection  of  the  bowel  (Fig.  435)-  The  advantages 
over  end-to-end  anastomosis  are  that  broader  contact  of  the  serous 
surfaces  can  be  secured  without  narrowing  the  lumen;  that  necrosis 
is  less  apt  to  occur,  as  the  mesenteric  vessels  are  not  involved  in 
the  suture;  that  the  opening  can  be  made  as  large  as  desired,  hence 
post-operative  contraction  may  be  discounted;  and  that  a  difference 
in  the  size  of  the  segments  makes  the  operation  no  more  difiEicult  or 
dangerous.  The  disadvantages  are  that  the  feces  are  apt  to  be 
propelled  past  the  opening  into  the  blind  end  of  the  proximal  seg- 
ment, which  may  give  way  under  the  pressure;  that  the  circular 
fibres  are  cut.  thus  predisposing  to  impaction  at  the  site  of  anasto- 


FiG.  435- — Lateral  anastomosis.  Fig.   436. 

mosis;  and  that  the  blind  end  of  the  distal  segment  may  invaginate. 
While  surgeons  differ  as  to  the  importance  to  be  attached  to  these 
considerations,  all  agree  that  lateral  anastomosis  is  safer  when  the 
bowel  is  not  completely  surrounded  by  peritoneum,  e.g.,  in  the 
ascending  and  descending  colon.  When  selected  after  resection  of 
the  bowel,  the  open  ends  of  the  gut  are  closed  by  sutures,  and  the 
anastomosis  effected  as  close  as  possible  to  the  ends  of  the  segments, 
care  being  taken  to  maintain  the  normal  direction  of  the  fecal 
current  whenever  possible  (Fig.  433).  When  the  ends  of  the  intes- 
tine cannot  be  sufficiently  mobilized  for  this  purpose,  the  bowel 
may  be  arranged  as  shown  in  (Fig.  436).  After  the  loops  have  been 
emptied  clamps  are  applied  and  the  operation  completed  in  the 
same  manner  as  gastroenterostomy  with  suture.  The  Murphy 
button  is  applied  much  in  the  same  way  as  in  end-to-end  anastomosis. 
A  purse-string  suture  passing  through  all  the  coats  is  introduced 
into  each  segment  of  bowel  opposite  its  mesenteric  attachment, 
incisions  made  into  each  loop  of  bowel  within  the  area  embraced 


764 


MANUAL    OF    SURGERY 


by  the  suture,  each  half  of  the  button  inserted,  the  sutures  drawn 
tight  and  tied,  and  the  button  locked. 

Lateral  implantation  (Fig.  438),  or  end-to-side  anastomosis 
may  be  performed  by  simple  suturing  or  by  means  of  the  Murphy 
button. 

Exclusion  of  intestine  whose  removal  is  impossible,  e.g..  because 
of  an  extensive  neoplasm,  or  whose  removal  is  unnecessary,  e.g.,  in 


Fig.  437. — Incomplete  exclusion  of  colon.      Pig.  438. — Unilateral  exclusion  of  colon. 

chronic  inflammatory  lesions,  may  be  performed  in  three  ways. 
(i)  The  bowel  above  and  below  the  diseased  segment  is  united  by 
lateral  anastomosis  (Fig.  437).  This  does  not  divert  the  fecal 
current  completely  and,  uaIcss  there  is  total  obstruction  in  the 
short-circuited  bowel,  is  often  followed  by  contraction  of  the  anasto- 
motic opening.      (2)  The  bowel  above  the  disease  is  severed,  the 

distal  end  closed,  and  the  proximal  end 
united  with  the  bowel  below,  either  by 
lateral  implantation  (Fig.  438)  or  by  lateral 
anastomosis.  This  operation  is  called  un- 
ilateral exclusion.  Its  disadvantages  are, 
when  applied  to  the  colon,  retrograde  trans- 
portation of  the  feces  and  diarrhea.  It 
really  creates  a  long  artificial  cecum,  in 
which  the  intestinal  secretions  and  the  re- 
FiG.  439.— Bilateral  exclusion  gurgitatcd  fcccs  may  accumulatc  (fecal  im- 
paction), putrefy  (gaspains^  generate  toxins 
(intoxication),  and  perhaps  cause  ulceration,  perforation,  and  death. 
These  dangers  may  be  lessened,  but  not  obviated,  if  the  lower  end 
of  the  ileum  is  anastomosed  with  the  transverse  colon  (ileotrans- 
verseostiomy) .  Lane  recommends  ileosigmoidostomy,  end-to-side 
(Fig.  438),  for  chronic  constipation  and  for  many  other  ills  that  he 
believes  are  due  to  intestinal  stasis.  (3)  The  bowel  is  anastomosed 
as  just  described,  and  then  the  lower  end  of  the  excluded  segment 


ABDOMEN  765 

divided  above  the  anastomosis  and  the  open  ends  of  the  gut  closed 
(bilateral  exclusion,  Fig.  439).  This  method  necessitates  drainage  of 
the  excluded  segment,  which  otherwise  would  become  distended  with 
retained  secretions,  causing  pain,  toxemia,  and  jM^ssibly  peritonitis 
from  perforation,  hence  if  the  excluded  segment  is  not  already  con- 
nected with  skin  by  a  fistula,  one  must  be  established.  One  or  both 
ends  of  the  excluded  bowel  may  be  left  open  and  fastened  to  the  skin. 
In  order  to  avoid  the  inconvenience  of  an  external  fistula  several 
suggestions  have  been  made.  The  ileum  may  be  united  with  the 
sigmoid  by  lateral  anastomosis  in  two  places,  and  ligated  between 
the  anastomoses.  A  lateral  anastomosis  may  be  made  between  the 
cecum  and  the  sigmoid  (typhlosigmoidostomy).  The  sigmoid 
may  be  divided,  the  lower  end  anastomosed,  end-to-end,  with  the 
cecum,  the  upper  with  the  side  ot  the  lower  segment  (typhlosigmoid- 
ostomy en  Y).  In  all  of  these  methods  both  ends  of  the  colon  are 
said  to  be  drained.  In  the  first  the  ileocecal  valve  would  probably 
interfere  with  the  drainage  of  the  cecum.  In  the  second  and  the 
third,  at  least  some  of  the  feces  would  prefer  the  normal  to  the 
artificial  route,  and  flow  up  the  ascending  colon.  In  all  a  stricture 
above  the  site  of  operation,  e.g.,  in  the  transverse  colon,  would 
create  two  culs  de  sac.  Hence  these  operations  do  not  exclude  the 
large  bowel,  and  after  bilateral  exclusion  one  must  accept  the  external 
fistula  or  excise  the  colon. 

APPENDICITIS 

The  vermiform  appendix  varies  in  length  from  a  fraction  of  an 
inch  to  one  foot,  but  is  generally  about  three  inches.  It  may  point 
in  any  direction,  but  most  frequently  it  runs  downward  and  inward 
or  upward  and  inward.  It  usually  arises  from  the  postero-internal 
part  of  the  cecum,  which  it  resembles  in  structure,  except  that  it 
contains  a  large  amount  of  lymphoid  tissue,  a  fact  which  has  gained 
for  it  the  title  "abdominal  tonsil."  Although  it  may  be  entirely 
retroperitoneal,  it  is  almost  always  supplied  with  a  mesentery  (meso- 
appendix),  in  whose  free  border  runs  the  artery  of  the  appendix, 
which  is  a  branch  of  the  posterior  ileocecal;  one  or  two  vessels  may 
run  also  outwards  on  the  body  of  the  organ  within  the  folds  of  the 
mesoappendix.  In  the  female  the  appendix  is  occasionally  con- 
nected with  the  ovary  by  a  fold  of  peritoneum  (appendiculo-ovarian 
ligament)  which  carries  a  small  artery  from  the  ovarian,  thus  giving 
additional  blood  supply.  The  orifice  of  the  appendix  is  slightly 
narrowed  by  a  mass  of  lymphoid  tissue,  called  the  valve  of  Gerlach. 


766  MANUAL    OF    SURGERY 

The  function  of  the  human  appendix  is  not  known,  although  some 
believe  it  has  a  sHght  influence  on  digestion  by  reason  of  its  secretion, 
,  The  causes  of  appendicitis  are  predisposing  and  exciting.  Among 
the  predisposing  causes  must  first  be  mentioned  the  peculiarities  of 
the  appendix  itself.  It  is  a  long,  narrow,  blind  sac  communicating 
with  the  intestinal  canal  and  often  constricted  at  its  orifice.  The 
mesoappendix  is  often  short,  thus  coiling  or  kinking  the  appendix 
and  interfering  with  its  drainage  and  blood  supply.  Although  it 
may  occur  at  any  age,  appendicitis  is  most  frequent  between  the 
tenth  and  thirtieth  years.  It  is  sHghtly  more  common  in  males, 
and  is  probably  more  frequent  in  the  summer  than  in  the  winter. 
Other  conditions  w^hich  predispose  to  this  affection  are  tonsillitis, 
rheumatism,  influenza,  and  disorders  of  the  gastrointestinal  canal, 
e.g.,  gastroenteritis,  dysentery,  typhoid  fever,  and  constipation. 
One  attack  markedly  predisposes  to  subsequent  attacks.  The 
exciting  causes  are  enteritis  (including  conditions  like  intestinal 
indigestion,  typhoid,  and  dysentery)  which  spreads  to  the  appendix, 
traumatism,  exposure  to  cold,  and  foreign  bodies.  Foreign  bodies, 
such  as  intestinal  parasites,  seeds  and  stones  are  uncommon,  but 
fecal  concretions  are  often  encountered.  Tuberculosis,  actino- 
mycosis, and  certain  neoplasms  also  may  involve  the  appendix,  and 
inflammation  of  neighboring  structures,  e.g.,  the  uterine  appendageS; 
may  cause  a  secondary  appendicitis.  No  matter  what  the  source  of 
irritation,  however,  the  most  important  factor  is  infection  of  the  walls 
with  micro-organisms,  especially  the  colon  bacillus.  The  ordinary 
pyogenic  bacteria,  particularly  the  streptococcus  pyogenes  and  less 
frequently  other  organisms,  also  are  found,  either  alone  or  as  a  mixed 
infection.  The  appendix  is  normally  inhabited  by  hordes  of  bacteria, 
which  become  vicious  only  when  they  enter  the  wall  of  the  appendix 
through  an  abrasion,  e.g.,  by  a  fecal  concretion,  or  through  the 
lymphatics  without  an  abrasion,  e.g.,  when  the  drainage  of  the  organ 
is  defective  as  the  result  of  .kinks,  adhesions,  tumors,  concretions, 
foreign  bodies,  or  swelKng  of  the  mucous  membrane  of  the  cecum. 
The  pathological  anatomy  varies  with  the  virulence  of  the  infection, 
the  depth  of  the  inflammation,  the  duration  of  the  process,  and  the 
complications.  In  catarrhal  appendicitis  the  mucous  membrane  is 
swollen  and  congested  and  sometimes  presents  hemorrhagic  foci ; 
the  process  may  subside  if  drainage  is  free,  or  it  may  extend  to  the 
outer  walls  {interstitial  appendicitis),  the  entire  organ  then  being 
swollen  and  congested,  and  containing  pus  {empyema  of  the  appendix), 
blood,  or  feces.  Interstitial  abscesses  also  may  be  found.  If  the 
appendix  empties  its  contents  into  the  cecum,  the  patient  may  recover 


ABDOMEN  767 

from  the  attack,  but  the  organ  is  permanently  crippled  and  a  chronic 
or  recurring  inllammation  ensues.  More  often  the  disease  pro- 
gresses to  ulceration  or  gangrene.  Ulcerative  appendicitis  may  arise 
also  primarily,  e.g.,  in  typhoid  fever  or  dysentery,  or  from  a  foreign 
body.  One  or  more  of  these  ulcers  may  perforate  (perforative 
appendicitis),  either  into  the  free  peritoneal  cavity,  or  much  more 
commonly  after  the  general  peritoneal  cavity  has  been  protected 
by  inflammatory  adhesions.  In  the  latter  instance  a  localized 
abscess  will  be  formed.  Ulcers  which  do  not  perforate,  but  cicatrize, 
cause  strictures  and  deformities  of  the  appendix.  When  such 
contraction  is  universal,  the  entire  cavity  may  disappear  {obliterating 
appendicitis).  The  appendix  occasionally  becomes  distended  wdth 
mucus  distal  to  a  stricture  (hydrops  or  mucocel  of  the  appendix). 
Gangrenous  appendicitis  may  follow  any  of  the  preceding  varieties, 
a  sudden  and  overwhelming  infection,  or  obstruction  to  the  blood 
supply,  e.g.,  as  the  result  of  kinks,  twists,  or  thrombosis.  This 
variety  may  develop  within  a  few  hours  (fulminating  appendicitis). 
The  organ  undergoes  moist  gangrene,  being  soft,  swollen,  and  green 
or  black  in  color,  and  soon  separates  from  the  healthy  tissues. 
In  fulminating  cases  it  may  lie  free  in  the  peritoneal  cavity.  In  any 
case,  however,  in  which  the  inflammation  progresses  beyond  the 
mucous  membrane,  adhesions  are  apt  to  form  about  the  appendix, 
thus  serving  as  a  protective  barrier  in  the  event  of  gangrene  or 
perforation.  The  exudate  formed  may  become  purulent,  even  in  the 
absence  of  perforation  and  gangrene.  The  situation  of  the  appendix 
determines  the  location  of  the  abscess,  which  may  rupture  through 
the  abdominal  wall,  into  a  neighboring  hollow  viscus,  or  into 
the  general  peritoneal  cavity.  Among  the  other  complications  of 
suppuration  about  the  appendix  are  intestinal  obstruction,  fecal 
fistula,  perforation  of  the  iliac  vein  or  artery,  psoitis,  lymphan- 
gitis or  lymphadenitis,  subphrenic  abscess,  empyema,  phlebitis 
(iliac,  femoral,  mesenteric,  or  portal),  and  pyemia  (abscess  of  the 
liver,  kidney,  spleen,  or  lung,  endocarditis,  meningitis,  and 
parotitis) . 

The  symptoms  may  be  described  under  two  headings,  according 
to  whether  the  disease  is  acute  or  chronic.  The  most  important 
symptoms  of  acute  appendicitis  are  pain,  tenderness,  and  rigidity 
of  the  muscles  over  the  appendix,  which  is  generally  in  the  right 
iliac  fossa,  but  may  be  in  the  loin,  pelvis  or  any  part  of  the  right  side 
of  the  abdomen;  in  rare  instances  it  is  to  the  left  of  the  median  line. 
The  first  symptom  is  pain,  which  usually  develops  suddenly,  is 
paroxysmal   in   the   beginning  and   confined    to   the   epigastric   or 


768  MANUAL    OF    SURGFRY 

umbilica]  region,  and  later  becomes  constant  and  localized  in  the 
region  of  the  appendix.  The  pain  in  the  appendiceal  region  is 
increased  by  direct  pressure  over  the  appendix,  and  by  indirect 
pressure  induced  by  movements  of  the  right  thigh,  abdominal 
respiration,  and  deep  palpation  of  the  left  abdomen.  Traction  on 
the  right  spermatic  cord  may,  by  stretching  the  peritoneum  in  the 
neighborhood  of  the  internal  inguinal  ring,  cause  acute  pain  especially 
when  the  appendix  is  situated  in  the  pelvis.  The  pain  may  dis- 
appear entirely  after  the  onset  of  gangrene  or  suppuration.  The 
situation  of  the  most  marked  tenderness  also  varies  with  the  situa- 
tion of  the  appendix,  hence  may  require  rectal  or  vaginal  examination 
for  its  development;  in  most  instances,  however,  it  is  at  McBurney's 
point  (one  and  one-half  to  two  inches  from  the  anterior  superior 
spine  of  the  right  ihum  on  a  line  running  to  the  umbilicus.  Fig.  376). 
The  skin  over  the  inflamed  area  also  may  be  hyper  esthetic.  Rigidity, 
often  board-like  in  character,  likewise  is  most  intense  over  the  appen- 
dix, and  its  degree  and  extent  usually  indicate  the  degree  and  extent 
of  the  underlying  inflammation.  Vomiting  occurs  with  the  epigas- 
tric pain,  then  subsides,  and  recurs  with  the  development  of  peri- 
tonitis. Constipation  is  present  in  about  two-thirds  of  the  cases. 
The  temperature  usually  rises  two  or  three  degrees,  but  in  many 
cases  there  is  no  fever  until  abscess,  peritonitis,  or  other  septic 
complications  ensue.  Chills  are  rare  and  generally  indicate  gangrene 
of  the  appendix  or  metastatic  abscesses.  The  pulse,  in  the  absence 
of  complications,  may  be  normal  or  but  slightly  accelerated;  it 
becomes  rapid  with  the  onset  of  peritonitis.  The  respirations  are 
costal,  but  the  rate  is  not  influenced  to  any  great  extent  until  the 
advent  of  peritonitis  develops.  The  facial  expression  may  be  that  of 
pain,  but  is  not  characteristic  in  the  absence  of  peritonitis.  The 
tongue  is  usually  coated.  Hematuria  may  occur  when  the  appendix 
lies  against  the  ureter  or  the  bladder.  The  late  symptoms,  in  a 
progressive  case,  are  those  of  peritonitis.  In  the  early  stages  the 
underlying  structures  cannot  be  palpated  because  of  the  muscular 
rigidity,  but  with  the  formation  of  an  abscess  or  a  fibrinous  exudate 
about  the  appendix,  a  mass  may  be  felt  and  sometimes  seen.  This 
tumor  is  smooth,  fixed,  usually  tympanitic,  and  rarely  fluctuating. 
After  the  infected  focus  has  become  well  encapsulated,  the  rigidity, 
often  disappears.  Rough  or  powerful  pressure  should  never  be 
used  in  acute  cases  because  of  the  danger  of  rupturing  the  appendix 
or  an  environing  abscess.  Leukocytosis,  increasing  with  the  extent 
of  the  infection,  unless  such  be  overwhelming,  is  a  sign  of  some  value 
when  considered  with  the  clinical  phenomena.     The  progress  of 


ABDOMEN  769 

the  disease  varies  greatly  in  different  instances.  In  the  mildest 
forms  in  which  the  infection  does  not  extend  beyond  the  appendix, 
complete  recovery  may  follow  in  a  few  days,  but  subsequent  attacks 
are  the  rule  {recurring  appendicitis).  In  fulminating  cases  the 
peritoneum  may  be  involved  within  a  few  hours.  Unfortunately  it 
is  impossible  to  foretell  from  the  character  of  the  symptoms  which 
cases  will  recover  and  which  will  progress  to  perforation,  gangrene, 
or  abscess  formation.  In  the  midst  of  even  the  mildest  symptoms, 
sudden  perforation  or  gangrene  with  their  disastrous  sequelai  may 
occur.  Chronic  appendicitis  may  be  such  from  the  beginning  or  it 
may  follow  an  acute  attack.  The  symptoms  are  pain  and  tenderness 
in  the  region  of  the  appendix  with  chronic  indigestion.  Occasion- 
ally a  thickened  appendix  may  be  felt.  Chronic  appendicitis  in 
which  acute  attacks  occur  at  intervals  is  called  relapsing  appendicitis. 
The  X-ray  signs  of  chronic  appendicitis  are  fixation  tenderness,  or 
distortion  of  the  appendix,  which  can  be  seen  after  an  opaque  meal. 
If  the  appendiceal  shadow  fails  to  appear  the  appendicitis  may  be 
obstructed,  obliterated,  filled  with  feces,  or  obscured  by  the  barium- 
filled  cecum.  Sometimes  the  appendiceal  shadow  persists  for  months. 
The  diagnosis  is  generally  easy,  but  may  be  difficult  or  impossible. 
In  many  cases  a  failure  to  make  a  definite  diagnosis  entails  no  serious 
consequences  to  the  patient,  because  operation  is  necessary  in 
order  to  deal  with  some  intraabdominal  surgical  lesion.  Embar- 
rassment to  the  surgeon,  however,  may  arise  owing  to  failure  to 
obtain  permission  to  remove  any  disease  that  may  be  present, 
especially  if  the  patient  be  a  female,  and  the  disease  ovarian.  Pain, 
tenderness,  and  rigidity  are  prominent  features  in  this  group  of  cases, 
which  includes  among  other  conditions  the  following :  Perforation  of 
any  portion  of  the  gastrointestinal  canal,  intestinal  obstruction, 
inflammation  of  Meckel's  diverticulum,  cholecystitis,  acute  pan- 
creatitis, thrombosis  or  embolism  of  the  mesenteric  vessels,  volvulus 
of  the  omentum,  tuberculous  peritonitis,  extrauterine  pregnancy, 
inflammatory  lesions  of  the  right  tube  or  ovary,  and  ovarian  cyst 
with  twisted  pedicle.  In  a  second  group  of  cases  the  trouble  lies 
in  the  kidney  or  the  ureter,  and  may  be  missed  even  during  an  intra- 
peritoneal exploration,  or,  if  discovered,  may  necessitate  a  separate 
incision,  and  perhaps  an  emergency  nephrectomy  without  investiga- 
tion of  the  functional  capacity  of  the  other  kidney.  Special  mention 
should  be  made  of  acute  hematogenous  infection  of  the  kidney, 
stone  in  the  kidney  or  ureter,  floating  kidney,  with  twisted  ureter, 
and  perinephric  abscess.     In  a  third  group  of  cases,  in  which  it  is  not 

always  possible  to  avoid  a  mistake  in  diagnosis,  nooperation  is  needed. 
49 


770  51.A.NUAL    OF.  SURGERY 

A  list  of  such  cases  will  be  foand  ander  ''Unnecessary  Abdomi- 
nal Section.""  Excluding  the  abdominal  wall  and  the  appendix,  a 
^  mass  in  the  right  iliac  region,  may  be  due  to  neoplasm  of  the  structures 
in  this  region,  particularly  carcinoma  of  the  cecum  and  sarcoma  of 
the  ilium,  ovarian  cysts,  enlarged  l\-mph  glands,  volvulus  of  the 
omentimi  or  the  intestines,  hematoma,  tuberculosis  or  actinomysosis 
of  the  cecum,  foreign  body  in  the  intestine,  fecal  impaction,  intus- 
s isception,  aneur}-sm,  abscess  (from  the  vertebras  or  pelvic  bones, 
iliopsoas  or  abdominal  muscles),  pelvic  celluhtis,  inflamed  unde- 
scended testicle,  properitoneal  hernia,  enlarged  gall-bladder,  dis- 
placed or  ectopic  kidney,  and  phantom  tumor.  Space  cannot  be 
spared  in  this  place  to  give  a  separate  enumeration  of  the  symptoms 
of  these  conditions,  but  in  most  instances  the  differential  diagnosis 
is  possible  if  care  is  taken  to  obtain  a  full  histor}-  and  make  a 
complete  examination. 

The  treatment  of  acute  appendicitis  is  operation  as  soon  as  the 
diagnosis  is  made.  There  are  certain  exceptions  to  this  rule,  e.g., 
the  presence  of  some  other  grave  malady  which  will  render  operation 
extremely  dangerous,  or  the  absence  of  a  competent  surgeon.  Under 
these  circumstances  or  when  operation  is  refused,  the  patient  should 
receive  the  medical  treatment  ad\ised  in  the  section  on  ''Peritonitis. " 
The  mortahty  with  medical  treatment  is  said  to  be  2^  per  cent.,  that 
of  early  operation  while  the  infection  is  still  confined  to  the  appendix 
is  less  than  i  per  cent. ;  in  cases  in  which  a  localized  abscess  has  formed 
the  mortaUty  of  operation  is  from  5  to  10  per  cent.,  in  those  with 
diffuse  peritonitis  between  10  and  25  per  cent.  The  practitioner  is 
sometimes  adx'ised  to  wait  for  an  interval  before  operating  in  cases 
with  mild  or  subsiding  sj-mptoms,  but  operation  in  these  cases  is  just 
as  safe  as  in  an  interval,  and  the  danger  of  a  sudden  exacerbation  is 
precluded.  In  appendicitis  with  peritonitis  a  few  surgeons  adopt  the 
Ochsner  method  of  treatment  (see  " Peritonitis "'j.  In  chronic  ap- 
pendicitis the  time  of  operation  may  be  arranged  to  suit  the  conveni- 
ence of  the  patient  and  the  surgeon.  If  a  patient  has  passed  through 
one  attack  of  undoubted  appendicitis,  removal  of  the  organ  is  recom- 
mended because  of  the  danger  of  subsequent  attacks;  this  ad^■ice 
becomes  progressively  stronger  with  the  number  of  attacks  which 
have  been  experienced. 

Operation  in  clean  cases,  i.e..  early  in  an  attack,  during  an  inter- 
val, or  in  chronic  cases,  is  as  follows:  The  abdomen  may  be  opened 
by  an  incision  through  the  outer  border  of  the  right  rectus  muscle, 
beginning  at  the  level  of  the  umbihcus  and  extending  downward 
two  or  more  inches,  according  to  the  amount  of  room  desired.     In  the 


ABDOMEN 


771 


McBurney  method  no  nerves  or  muscles  are  divided  and  subsequent 
hernia  is  practically  impossible.  A  two  or  three  inch  skin  incision  is 
made  in  the  direction  of  the  fibers  of  the  external  oblique,  the  center 
of  the  incision  being  about  one  and  one-half  inches  from  the  anterior 
superior  spine  of  the  ilium  on  a  line  to  the  umbilicus.  The  libers 
of  the  external  oblique  are  separated  and  retracted,  likewise  the 


Fig.  440. — Intermuscular  incision.  Pig.  441. — Ligation  of  mesqappendix. 

fibers  of  the  internal  oblique  and  transversalis  muscles,  which  run 
almost  at  right  angles  to  the  superficial  wound  (Fig.  440) .  The  trans- 
versalis fascia  and  peritoneum  are  severed  in  the  same  direction  as  the 
internal  oblique.  Before  dealing  with  the  appendix  the  adjacent 
intestine,   the  hernial  rings  in  the  immediate  vicinity,  the  ureter, 


Pig.  442. — Inversion.     The  hemostat  and  hands  are  not  shown. 

and  in  the  female  the  pelvic  organs  should  be  palpated.  The 
appendix  may  be  hooked  up  as  the  finger  is  brought  out  of  the 
pelvis.  In  other  cases  it  will  be  necessary  to  identify  the  cecum,  and 
follow  the  anterior  longitudinal  band,  which  always  leads  to  the  base 
of  the  appendix.  If  adhesions  are  encountered,  they  should  never 
be  separated  without  protecting  the  general  peritoneal  cavity  with 


772  '  MANUAL    OF    SURGERY 

gauze,  as  they  may  harbor  a  focus  of  suppuration.  The  mesoappen- 
dix  is  perforated  close  to  the  cecum  with  an  aneurysm  needle,  armed 
with  catgut  (Fig.  441)  ligated,  and  divided.  Hemostatic  forceps 
are  placed  on  the  appendix  near  its  base,  to  prevent  soiling  of  the 
wound  during  amputation,  which  may  be  effected  by  one  of  a  num- 
ber of  different  methods.  The  easiest  plan  is  to  crush  the  base  of 
the  appendix  with  a  second  pair  of  forceps,  ligate  the  crushed  tissue 
with  catgut,  amputate  beyond  the  ligature,  and  cover  the  stump  with 
a  purse-string  inversion  suture  of  silk  or  celluloid  thread,  after  touch- 
ing the  exposed  mucous  membrane  with  carbolic  acid,  and  then  with 
alcohol.  Since  this  method  necessitates  the  strangulation  of  infected 
tissue,  which  is  occasionally  followed  by  abscess,  the  author  proceeds 
as  follows  The  ligated  stump  of  the  mesoappendix  is  buried  by 
means  of  a  Lembert  suture  of  celluloid  thread,  which  is  continued 
as  far  as  the  base  of  the  appendix,  when  the  needle  is  arrested  in 
its  passage  through  the  folds  that  have  been  raised  on  each  side  of 
the  appendix  (Fig.  442),  and  the  appendix  amputated  close  to  the 
cecum,  theleft  thumb  being  placed  beneath  the  eye  half  of  the  needle, 
the  left  index  finger  beneath  the  distal  half,  to  insure  against  retrac- 
tion of  the  bowel  into  the  abdomen.  After  inspecting  the  cut  surface, 
to  make  certain  that  there  is  no  bleeding,  the  needle  is  pulled  through, 
thus  inverting  the  edges  of  the  wound,  the  closure  being  completed 
with  two  or  three  additional  stitches.  The  suture  hne  is  then  buried 
by  a  second  continuous  Lembert  suture,  made  with  the  same  thread, 
and  terminated  at  the  point  of  origin  of  the  first  suture.  Rarely  a 
bleeding  point  is  observed  at  the  site  of  amputation,  in  which  event 
the  wound  is  made  dry  with  an  extra  stitch  before  completing  the 
inversion.  If  the  appendix  is  normal  or  not  sufficiently  diseased  to 
account  for  the  symptoms,  the  kidney  and  the  intraperitoneal  organs 
not  already  examined  should  be  palpated,  which  can  be  done  only 
through  a  wound  large  enough  to  admit  the  hand.  The  McBurney 
incision  can  be  extended  by  cutting  the  sheath  of  the  rectus  trans- 
versely and  retracting  the  muscle  toward  the  middle  line.  At  the 
completion  of  the  operation  the  peritoneum  is  closed  with  a  purse- 
string  suture  of  catgut,  one  end  of  whch  is  passed  from  within  out 
wards  through  the  transversalis  and  the  internal  oblique  muscles  and 
used  as  a  continuous  stitch  to  draw  these  structures  together,  after 
which,  in  a  similar  manner,  it  perforates  and  approximates  the  ex- 
ternal oblique.  The  sheath  of  the  rectus,  if  severed,  is  repaired  at 
the  same  time.  The  skin  is  closed  with  a  continuous  suture  of  silk 
worm  gut. 

Operation  for  appendiceal  abscess  is  performed   through  an 


ABDOMEN  773 

incision  made  owr  the  mass.  If  edema  of  the  abdominal  wall  be 
found,  the  abscess  is  probably  adherent  to  the  parietes,  and  will  be 
opened  on  cautiously  deepening  the  wound.  All  that  is  then  needed 
is  to  insert  a  gauze  drain  and  allow  the  cavity  to  heal  by  granulation. 
If,  however,  the  appendix  is  loose  in  the  abscess  cavity,  or  can  be 
removed  without  opening  the  general  peritoneal  cavity,  such  should 
be  done.  In  other  cases  the  appendectomy  should  be  performed 
after  the  wound  has  healed,  when  there  is  no  longer  danger  of  infect- 
ing the  peritoneum.  If  the  mass  is  not  adherent  to  the  parietes,  it 
should  be  isolated  from  the  general  peritoneal  cavity  by  gauze  pack- 
ing. A  small  opening  is  then  made  into  the  abscess  by  separating 
the  adhesions  with  the  finger,  and  the  pus  removed  with  gauze  pads 
as  quickly  as  it  appears.  When  the  pus  ceases  to  flow,  the  opening 
is  enlarged  with  the  finger,  the  cavity  dried  with  gauze,  and  the 
appendix  removed  by  one  of  the  methods  already  mentioned,  using 
catgut,  however,  for  the  inversion  suture,  since  a  non-absorbable 
suture  in  these  cases  may  give  rise  to  a  troublesome  sinus.  The 
cavity  is  again  dried,  and. then  drained  with  gauze;  the  author  uses 
the  Mikulicz  drain,  as  described  under  "Surgical  Technic"  (chap. 
iv).  After  the  outer  packing  is  removed,  the  superfluous  portion 
of  the  wound  is  closed  with  sutures. 

For  operation  for  diffuse  peritonitis  following  appendicitis  see 
"Peritonitis." 

The  sequelae  of  operation  in  abscess  cases,  or  in  those  complicated 
by  peritonitis,  are  secondary  abscess,  phlebitis,  intestinal  obstruc- 
tion, fecal  fistula,  suppuration  of  the  superficial  wound,  and  hernia. 
The  complications  of  the  disease  itself  have  already  been  given  in 
the  paragraph  on  the  "Pathological  anatomy." 

Appendicostomy  (Wier's  operation)  is  employed  to  permit  irriga- 
tion of  the  colon  in  chronic  dysentery  and  other  ulcerative  lesions  of 
the  large  bowel.  The  abdomen  is  opened  by  a  McBurney  incision, 
the  mesoappendix  ligated  and  severed,  the  appendLx  sutured  to  the 
parietal  peritoneum  and  the  skin,  the  superfluous  portion  of  the 
wound  closed,  the  appendix  opened  to  make  sure  that  it  is  patulous 
(if  strictured  a  Gibson  operation,  as  described  under  "Colostomy," 
is  indicated) ,  a  ligature  applied  to  prevent  leakage,  and  after  several 
days  the  protruding  part  of  the  appendix  amputated.  The  colon 
may  now  be  irrigated  daily  with  salt  solution,  silver  nitrate,  1-5000, 
bismuth  and  starch  water,  i  dram  to  the  ounce,  etc.,  by  passing  a 
catheter  through  the  appendix  and  introducing  a  tube  into  the  rectum 
When  the  fistula  is  no  longer  needed  it  may  be  closed  by  cauterizing 
the  mucous  membrane. 


774  MANUAL    OF    SURGERY 

THE  LIVER 

For  injuries  of  the  liver  see  contusions  and  wounds  of  the  abdo- 
men. 

Abscess  of  the  liver  results  from  direct  infection,  e.g.,  through  a 
wound;  infection  by  contiguity,  e.g.,  from  a  subphrenic  abscess; 
ascending  infection  through  the  bile  ducts,  e.g.,  in  suppurative 
cholangitis;  lymphogenous  infection,  e.g.,  in  rectrocecal  cellulitis 
and  appendicitis  (Munroe) ;  or  from  hematogenous  infection.  In 
the  last  instance,  which  is  the  most  frequent,  the  bacteria  reach  the 
liver  by  way  of  the  hepatic  artery  (general  pyemia) ;  more  commonly, 
by  way  of  the  portal  vein  (portal  pyemia)  from  infective  lesions  in 
the  area  drained  by  this  vein,  e.g.,  appendicitis,  rectal  affections, 
suppuration  of  the  pelvic  organs,  and  dysentery  or  other  forms  of 
intestinal  ulceration;  or,  exceptionally,  by  way  of  the  hepatic  vein 
(retrograde  embolism) ;  or,  in  the  new-born,  the  umbiUcal  vein  as  the 
result  of  infection  of  the  umbilicus.  The  pyogenic  organisms  most 
frequently  found  are  streptococci,  staphylococci,  and  the  colon 
bacillus.  In  tropical  abscess,  which  follows  amebic  dysentery, 
cultures  are  frequently  sterile,  the  pyogenic  bacteria  originally  pres- 
ent having  perished  with  the  lapse  of  time;  the  pus  is  thick,  chocolate 
colored,  and  contains  blood,  necrotic  liver  cells,  and  a  few  leukocytes; 
the  ameba  is  absent  in  20  per  cent,  of  the  cases.  Hydatid  cysts 
may  suppurate,  and  actinomycetes,  ascarides,  distoma,  and  coccidia 
are  possible  but  rare  causes  of  hepatic  suppuration.  Tropical  and 
traumatic  abscesses  are  usually  solitary  and  occupy  the  right 
lobe;  pyemic  abscesses  small,  multiple,  and  hence  rarely  amenable  to 
treatment. 

The  symptoms  in  acute  and  pyemic  abscesses  are  pain  reflected 
to  the  right  shoulder,  tenderness  and  enlargement  of  the  liver,  oc- 
casionally friction  sounds  owing  to  involvement  of  the  peritoneum, 
rarely  edema  of  the  skin  or  fluctuation,  chills,  fever,  sweats,  leukocy- 
tosis, perhaps  slight  jaundice,  and  sometimes  cough  from  irritation 
of  the  phrenic  nerve  or  invasion  of  the  lung.  In  chronic  and  tropical 
abscesses  there  may  be  few  or  no  symptoms,  and  no  leukocytosis.  In 
the  latter  the  ameba  may  be  found  in  the  stools.  The  X-rays  may 
show  the  enlargement  of  the  liver  and,  if  the  abscess  is  near  the 
diaphragmatic  surface,  a  dome-shaped  projection.  The  abscess 
may  break  into  the  peritoneal  cavity,  one  of  the  hollow  viscera,  the 
pleura,  the  lung,  the  pericardium,  or  into  the  vena  cava  or  portal 
vein;  or  it  may  point  externally  through  the  abdominal  wall.  The 
diagnosis  may  be  confirmed  by  aspiration,  the  needle  being  inserted 


ABDOMEN  775 

in  the  seventh  or  eighth  intercostal  space  between  the  axiUary  Hnes, 
below  the  costal  arch  in  the  right  nipple  line,  or  posteriorly  in  the 
ninth  or  tenth  interspace  vertically  below  the  angle  of  the  scapula. 
One  should  be  j^repared  to  proceed  immediately  with  operation  if  pus 
is  found. 

The  treatment  is  hepatotoviy  by  the  abdominal  or  thoracic  route, 
depending  upon  the  situation  of  the  abscess.  If  the  former  is 
chosen,  the  abdomen  is  opened,  usually  by  a  longitudinal  incision, 
below  the  costal  arch.  If  the  liver  is  adherent  to  the  abdominal  wall, 
the  abscess  may  be  opened  without  danger  of  contaminating  the 
peritoneal  cavity.  In  the  absence  of  adhesions  the  peritoneal  cavity 
must  be  protected  by  gauze  packing.  The  abscess  is  located  with 
hollow  needle,  and  opened  by  passing  a  knife  or  a  cautery  blade  along 
the  needle.  The  abscess  is  irrigated,  and  drained  with  a  rubber  tube, 
the  free  portion  of  the  cavity  being  slightly  packed  with  gauze. 
After  removing  the  gauze  which  protects  the  peritoneal  cavity, 
the  liver  below  the  opening  of  the  abscess  may  be  sutured  to  the 
abdominal  wall.  When  the  abscess  is  high  on  the  dome  of  the 
liver,  the  transpleural  or  thoracic  operation  is  indicated.  The  ab- 
scess is  located  with  the  needle  as  directd  above,  the  rib  below  the 
needle  excised,  and,  if  the  pleural  cavity  is  obliterated  at  this  point  by 
adhesions,  the  abscess  opened  as  previously  described.  If  there  are 
no  adhesions,  the  two  layers  of  the  pleura  should  be  stitched  together 
with  catgut. 

Cysts  of  the  liver  arising  from  dilatation  of  the  lymph  spaces  are 
called  simple  serous  cysts.  They  may  be  single  or  multiple,  large  or  small 
but  seldom  cause  symptoms.  Polycystic  disease  of  the  liver  is  usually 
congenital  and  often  associated  with  cystic  disease  of  the  kidneys; 
almost  the  whole  organ  is  converted  into  serous  cysts  of  various  sizes. 
Both  these  varieties  as  well  as  cystic  adenoma  and  dermoids  are 
very  rare.     Hydatid  cysts  are  considered  in  the  next  paragraph. 

Hydatid  cysts  are  found  more  frequently  in  the  liver  than  in  any 
other  portion  of  the  body.  The  general  facts  concerning  these  cysts 
and  the  composition  of  hydatid  fluid  are  given  in  chap.  xiii. 

The  symptoms  develop  slowly.  The  swelling  moves  with  respira- 
tion and  is  seldom  painful.  When  superficial,  fluctuation  and  hydatid 
fremitus,  or  thrill,  may  be  obtained;  the  latter  is  due  to  the  rubbing 
together  of  the  daughter  cysts.  When  deeply  situated  the  cyst 
may  be  mistaken  tor  a  neoplasm.  Pressure  on  the  lung  causes 
dyspnea;  on  the  stomach  or  bowel,  vomiting  and  indigestion;  on 
the  blood  vessels,  ascites  and  edema  of  the  legs;  on  the  bile  ducts, 
jaundice,  which  is  rare.     Hydatid  urticaria  and  toxemia  occur  most 


776  MANUAL    OF    SURGERY 

often  after  rupture  into  the  periteoneal  acivity.  Examination  of  the 
blood  reveals  eosinophilia.  The  X-rays  may  give  the  same  informa- 
tion as  in  abscess  of  the  liver.  Aspiration  may  be  used  for  diagnostic 
purposes,  but  only  immediately  before  operation.  The  cyst  may 
shrink  and  the  contents  become  inspissated,  or  it  may  enlarge,  with 
or  without  suppuration,  and  burst  in  one  of  the  situations  just 
mentioned  under  abscess  of  the  liver. 

The  treatment  is  much  like  that  of  abscess,  except  that  the  germ- 
inal layer  (endocyst)  should,  it  feasible,  be  peeled  out.  After  protect- 
ing the  abdominal  cavity,  the  cyst  is  aspirated,  opened  with  the 
cautery  or  the  knife,  the  daughter  cysts  and  the  endocyst  removed, 
and  the  cavity  drained,  after  stitching  the  edges  of  the  opening  to 
the  abdominal  wall.  Small  cysts  may  be  completely  excised.  Sim- 
ple aspiration  and  aspiration  followed  by  injections  are  not  recom- 
mended. 

Tumors  of  the  liver  are  usually  secondary,  hence  multiple. 
Among  the  primary  tumors  are  carcinoma,  sarcoma,  endothelioma, 
angioma,  fibroma,  adenoma,  lipoma,  and  myxoma.  Gummata  and 
thick-walled  hydatid  cysts  may  closely  simulate  neoplasms.  When 
operable  the  growth  may  be  resected  with  the  knife  or  the  thermo- 
cautery, after  surrounding  it  with  a  series  of  interlocking  ligatures 
of  silk  or  catgut,  introduced  with  a  blunt  needle.  The  circulation 
can  be  controled  temporarily  by  compressing  the  vessels  at  the  hilus. 
As  after  rupture  of  the  liver  (see  "Contusions  of  the  Abdomen") 
hemostasis  may  be  eflfected  by  tamponage  with  muscle,  omentum, 
or  fat,  and  a  transplant  of  fascia  employed  to  prevent  tearing  out  of 
the  sutures.  When  the  growth  is  pedunculated  it  may  be  secured 
extraperitoneally  by  transfixing  its  base  with  long  pins,  and  then 
removed  after  constricting  the  pedicle  below  the  pins  with  an  elastic 
ligature,  which  is  left  in  place. 

Hepatoptosis,  or  floating  liver,  is  generally  a  part  of  splanchnop- 
tosis. There  may  be  pain,  vomiting,  and  general  weakness,  with, 
in  some  cases,  jaundice  and  ascites.  The  prolapsed  organ  may  be 
outlined  by  palpation.  The  treatment  is  that  of  splanchnoptosis. 
When  other  measures  fail,  the  liver  may  be  sutured  to  the  anterior 
abdominal  wall  with  a  blunt  needle  and  silk  or  catgut  {hepatopexy). 
In  partial  ptosis,  or  floating  lobe,  e.g.,  the  result  of  tight  lacing  or 
cholelithiasis  {RiedeVs  lobe),  the  cause  should  be  removed.  The 
floating  lobe  can  be  supported  by  suturing  the  ligamentum  teres  or 
the  gall-bladder  to  the  abdominal  wall,  but  this  is  rarely  necessary. 
Excision  of  a  linguitorm  projection  also  has  been  done. 


ABDOMEN  777 

In  portal  cirrhosis  of  the  liver  with  ascites,  attempts  have  been 
made  (a)  to  prevent  the  elTiision  of  fluid  into  the  j)eritonel  cavity 
by  reheving  the  venous  congestion  through  an  artificial  collateral 
circulation  between  the  portal  and  the  systemic  vessels  f epiplopexy) , 
or  through  an  anastomosis  between  the  vena  cava  and  the  portal 
{Eck's  fistula)  or  superior  mesenteric  vein,  or  between  the  superior 
mesenteric  and  ovarian  veins;  and  (b)  to  drain  the  effusion  into  the 
subcutaneous  or  retroperitoneal  cellular  tissue  (by  leaving  an  opening 
in  the  peritoneum,  by  suturing  the  edges  of  the  opening  in  the  peri- 
toneum to  the  cellular  tissues,  by  placing  the  omentum  in  the 
abdominal  wall,  by  silk  threads,  wire,  tubes),  or  into  the  veins  by 
anastomosing  the  internal  saphenous  vein  with  the  peritoneum.  In 
epiplopexy  {Tabna's  operation)  the  fluid  is  drawn  ofT  by  a  puncture 
above  the  pubes,  and  the  abdomen  opened  above  the  umbilicus. 
The  external  surface  of  the  liver  and  the  spleen  and  the  apposed 
parietal  peritoneum  are  scrubbed  with  gauze,  after  which  the  omen- 
tum is  sutured  to  the  abdominal  wall.  The  wound  is  then  closed, 
and  the  freshened  intraperitoneal  surfaces  held  together  by  a  tight 
bandage  or  adhesive  plaster  applied  to  the  upper  abdomen.  About  lo 
per  cent,  of  the  patients  thus  treated  are  permanently  relieved  of  the 
ascites,  20  per  cent,  temporarily  benefited.  Direct  transference  of 
blood,  as  in  the  Eck- fistula,  aside  from  its  technical  difficulties,  may 
cause  emboUsm,  alimentary  intoxication  (because  the  blood  does 
not  flow  through  the  liver),  or  acute  general  infection  (because  the 
intestinal  mucosa  does  not  always  oppose  a  sufficient  barrier  to 
microorganisms) ,  hence  cannot  be  recommended.  The  drainage  opera- 
tions give  only  transient  relief,  as  the  opening  is  plugged  with  omen- 
tum or  closed  by  cicatrization,  the  foreign  body  encapsulated,  the 
vein  thrombosed.  Our  own  conclusions  are  as  follows:  (i)  Cirrhosis 
of  the  liver  cannot  be  cured  by  operation;  if  it  could,  the  operation 
ought  to  be  performed  before  the  ascites  appears.  (2)  As  syphilitic 
cirrhosis  can  be  greatly  benefited  or  perhaps  cured  by  medical  treat- 
ment, it  should,  if  possible  be  excluded  in  all  cases  before  deciding 
on  operation.  (3)  The  diagnosis  of  the  cause  of  the  ascites,  which 
is  merely  a  symptom,  is  often  difficult.  The  liver  may  be  large  or 
small  in  portal  cirrhosis.  In  all  forms  of  ascites,  it  may  be  pushed  up 
or  rotated,  and  give  a  diminished  area  of  dulness  on  percussion,  or 
the  ascites  may  be  so  great  that  the  size  of  the  liver  cannot  be  de- 
termined by  external  examination;  hence,  (4)  unless  there  are 
contraindications  (serious  disease  of  the  heart,  lungs,  kidneys,  or 
syphilis),  all  cases  should  be  operated  upon  early,  for  the  purpose  of 
diagnosis,  and  with  the  hope  that  something  may  be  found  that  is 


778  MANUAL    OF    SURGERY 

amenable  to  surgical  treatment.  If  cirrhosis  is  present  epiplopexy 
may  be  performed;  if  cholelithiasis,  the  stones  (^^ which  may  be  the 
cause  or  the  result  of  cirrhosisj  should  be  removed;  if  chronic 
pancreatitis,  the  gall-bladder  may  be  drained;  if  splenomegaly, 
(Banti's  disease),  splenectomy  is  to  be  considered.  Mayo  suggests 
splenectomy  for  the  purpose  of  reducing  the  amount  of  blood  carried 
to  the  liver.  Xot  infrequently  the  surgeon  will  find,  instead  of  hepa- 
tic cirrhosis,  tuberculous  peritonitis,  and  less  often  an  ovarian  papil- 
loma, a  tumor  in  the  portal  region,  carcinomatosis  of  the  peritoneum, 
or  capsular  cirrhosis  (perihepatitis; ,  in  which  the  liver  is  covered  with 
a  hyaline  fibrous  tissue  resembling  the  icing  on  a  cake,  and  in  which 
there  is  sometimes  a  similar  change  in  the  peritoneum  covering  the 
other  abdominal  organs,  in  the  pericardium,  and  in  the  pleural 
membranes  (polyserositis).  The  difficulty  in  diagnosis  referred  to 
above  promises  to  diminish  with  the  development  of  X-ray  inves- 
tigations after  the  production  of  an  artificial  pneumoperitoneum. 
The  ascitic  fluid  is  withdrawn  by  tapping,  and  the  trocar  connected, 
by  means  of  a  rubber  tube,  -with  a  rubber  bag  (such  as  is  used  in 
nitrous  oxide  anesthesia),  which  holds  three  or  four  litres  of  oxygen. 
The  abdomen  is  then  inflated  by  slight  pressure  on  the  bag  (W.  H. 
Stewart) .  The  oxygen  is  absorbed  within  24  hours.  By  this  method 
the  parenchymatous  organs  and  solid  tumors  can  be  demonstrated 
with  great  clearness.  Biliary  cirrhosis  without  ascites  has  been 
treated  by  cholecystostomy,  cholecystogastrostomy,  and  cholecysto- 
duodenostomy.  Operation  is  particularly  indicated  if  there  is  a 
complicating  cholelithiasis  or  chronic  pancreatitis.  One  must  be 
sure  that  the  condition  is  biliary  cirrhosis,  and  not  hemolytic  jaun- 
dice, since  the  latter  is  curable  by  splenectomy. 

THE  BILIARY  PASSAGES 

Inflammation  may  attack  the  bile  ducts  and  the  gall-bladder 
simultaneously  or  separately.  The  cause,  excluding  poisons  like 
phosphorous  and  arsenic,  is  always  infection,  which  ascends  from  the 
duodenum,  or,  more  often,  arrives  by  way  of  the  blood  stream 
through  one  of  the  paths  mentioned  under  ''Abscess  of  the  Liver." 
The  portal  vein  is  the  favorite  route,  because  it  drains  the  intestine 
which,  even  normally,  contains  hordes  of  bacteria.  The  hepatic 
artery  serves  to  convey  the  microorganisms  to  the  liver  in  systemic 
infections,  e.g..  typhoid,  pneumonia,  influenza,  septicemia,  and 
pyemia.  In  hematogenous  infection  the  bacteria  are  deposited 
directly  from  the  blood,  e.g.,  in  the  walls  of  the  gall-bladder,  or  are 


ABDOMEN  779 

excreted  with  the  l^ile  and  descend  to  the  affected  part.  The  or- 
ganisms most  freciuently  found  are  the  colon  bacillus,  the  tyjihoid 
bacillus,  the  paratyphoid  bacillus,  and  the  ordinary  pyogenic  bac- 
teria, especially  the  streptococcus.  Bacteria  excreted  by  the  liver 
may  produce  no  evil  effects,  unless  there  is  local  irritation,  e.g.,  from  a 
stone,  or  obstruction  to  the  ducts,  which  obstruction  may  be  in- 
trinsic, e.g.,  from  stones  (the  most  frequent  cause),  plugs  of  mucus, 
inspissated  bile,  ])seudomembrane,  inflammatory  swelling  of  the 
mucosa,  stricture,  or  animal  parasites,  or  extrinsic,  e.g.,  from  pan- 
creatitis, lymphadenitis,  adhesions,  tumors,  aneurysm,  or  prolapse 
of  the  kidney  or  liver  leading  to  kinking  of  the  ducts.  Obstruction 
is  rarely  due  to  congenital  absence  or  atresia  of  one  or  more  of  the 
biliary  passages. 

Cholangitis,  or  inflammation  of  the  biliary  ducts,  may  be  acute 
(catarrhal  or  suppurative)  or  chronic.  Acute  catarrhal  cholangitis 
{catarrhal  jaundice)  is  dealt  with  by  the  physician  and  need  not  be 
discussed  here.  Suppurative  cholangitis  causes  the  same  symptoms 
as  septicemia  or  pyemia,  with  an  enlarged  and  tender  liver  and  a 
varying  degree  of  jaundice.  The  treatment  is  that  of  pyemia,  with 
the  removal,  if  possible,  of  any  obstruction  to  the  flow  of  bile,  and 
drainage  of  the  gall-bladder  or  common  duct. 

Chronic  catarrhal  cholangitis  may  follow  the  acute  form,  but  is 
usually  the  result  of  obstruction  of  the  bile  ducts.  The  symtoms  are 
persistent  jaundice,  in  many  cases  recurring  attacks  of  fever  associated 
wdth  sweats  {Charcot^ s  intermittent  fever);  and  often  enlargement 
and  tenderness  of  the  liver,  with  asthenia  and  emaciation. 
The  complications  are  suppurative  cholangitis,  dift"use  hepatitis, 
abscess  of  the  liver,  cirrhosis  of  the  liver,  pylephlebitis,  chole- 
cystitis, perforation  of  the  ducts,  pancreatitis,  endocarditis,  pleurisy, 
pneumonia,  and  other  septic  maladies.  The  treatment  is  removal  of 
the  cause  when  possible,  and  drainage  of  the  biliary  ducts  by  one  of 
the  operations  to  be  described  later. 

Cholecystitis,  or  inflammation  of  the  gall-bladder,  is,  in  the 
majority  of  cases,  associated  with  gall-stones,  either  as  the  cause  or 
the  result.  As  wdth  the  appendix  the  pathologic  changes  depend 
upon  the  virulence,  depth,  and  duration  of  the  inflammation,  and  the 
complications. 

Acute  cholecystitis  of  the  catarrhal  variety  may  subside  if  there  is 
no  interference  with  biliary  drainage,  or  eventuate  in  one  of  the 
varieties  to  be  mentioned  below\  Acute  interstitial  cholecystitis, 
in  which  the  outer  walls  also  are  invaded,  is  more  apt  to  cause  per- 
manent trouble,  and,  if  suppurative,  may  lead  to  intramural  ab- 


780  MANUAL   OF    SURGERY 

scesses.  Suppurative  cholecystitis  is  often  caused  or  complicated  by 
obstruction  to  the  cystic  duct,  if  not  by  a  calculus,  by  inflammatory 
swelling  or  a  plug  of  mucus;  as  a  consequence  the  gall-bladder  is 
distended  with  bile,  mucus,  and  pus  {empyema  of  the  gall-bladder) . 
Ulcerative  cholecystitis  may  follow,  or  ulceration  may  arise  from  the 
pressure  of  a  stone.  In  these  cases  perforation  may  take  place, 
either  into  the  general  peritoneacal  cavity,  or  more  often  after 
the  formation  of  adhesions  (pericholecystitis),  which,  likewise, 
may  result  from  any  nonperforative  infection  of  the  gall-bladder 
that  has  progressed  beyond  the  mucous  membrane.  In  suppurative 
pericholecystitis  the  abscess  may  extend  up  in  front  of  the  liver 
(subphrenic  abscess),  or  empty  into  the  free  peritoneal  cavity, 
the  stomach,  the  intestine,  or  rarely  through  the  abdominal  wall,  thus 
resulting  in  an  internal  or  an  external  bihary  fistula.  Nonperforating 
ulcers  may,  by  cicatrization,  produce  strictures  of  the  cystic  duct, 
similar  deformities  of  the  gall-bladder,  and  occasionally,  when  the 
contraction  is  universal,  total  obliteration  of  this  organ  (cf.  *' Ob- 
literating Cholecystitis"  below).  Gangrene  is  caused  by  virulent 
infection  or  ischemia,  or  both.  Ischemia  is  due  to  over  distention 
of  the  gall-bladder,  or  thrombosis  or  other  form  of  obstruction  to 
the  blood  supply.  A  large  calculus  in  the  cystic  duct  may,  by 
damming  up  the  secretions  and  pressing  upon  the  cystic  artery,  be 
responsible  for  both  forms  of  ischemia.  The  gangrene  is  of  the 
the  moist  variety  and  the  contents  of  the  gall-bladder  are  mixed  with 
blood.     Pseudomemhraneous  cholecystitis  is  very  rare. 

Chronic  cholecystitis  of  the  catarrhal  variety  is  often  accompanied 
by  enlargement  of  the  glands  of  the  mucosa,  forming  papillary 
projections,  the  apices  of  which  become  eroded  and  stained  with  bile 
(strawberry  gall-bladder).  Sometimes  these  glands  hypertrophy  to 
such  an  extent  as  to  justify  the  term  papillomatous  cholecystitis, 
and  occasionally  one  or  more  may  become  distinctly  polypoid  {papil- 
loma of  the  gall-bladder) ;  in  these  cases  cancerization  is  a  possibility. 
Prolonged  obstruction  of  the  cystic  duct  with  chronic  catarrhal 
cholecystitis,  i.e.,  without  serious  infection,  leads  to  distention  of  the 
gall-bladder  with  mucoid  fluid,  the  bile  having  been  absorbed  (hy- 
drops cystidis  felleci).  Dilatation  of  the  common  and  the  hepatic 
ducts  follows,  for  the  reasons  given  under  "Cholecystectomy." 
Chronic  interstitial  cholecystitis  converts  the  normal  net-like  rugae  of 
the  mucosa  into  prominent  ridges  of  scar  tissue  and  causes  fibroid 
thickening  of  the  whole  wall,  which  is  sometimes  followed  by  great 
contraction,  the  gall-bladder  being  reduced  to  a  fibrous  cord  (ob- 
literating cholecystitis).  In  this  event,  as  in  hydrops,  the  common 
and  the  hepatic  ducts  may  become  permanently  dilated. 


ABDOMEN  781 

The  symptoms  of  cholecystitis  with  and  without  calculi  are  so 
nearly  alike  that  the  two  conditions  cannot  be  differentiated,  hence 
the  symptomatology  of  "gall-bladder  disease"  is  considered  under 
"Cholelithiasis." 

The  treatment  of  acute  catarrhal  cholecystitis  is  medical,  espe- 
cially when  the  condition  arises  in  the  course  of  some  general  disease 
like  enteric  fever  and  is  not  associated  with  severe  symptoms. 
Should  the  symptoms  persist,  however,  or  become  severe,  operation 
will  be  demanded.  The  indications  for  cholecystostomy  and  chole- 
cystectomy in  cholecystitis  are  noted  in  the  sections  dealing  with 
these  operations. 

Cholelithiasis  (gall-stones)  is  found  in  from  5  to  10  per  cent, 
of  all  autopsies.  It  is  due  to  one  of  the  following  conditions:  (i) 
infection,  (2)  bihary  stasis,  (3)  hypercholesterinemia.  Which  of 
these  is  the  primary  or  predominating  cause  is  a  matter  of  dispute, 
and  doubtless  varies  in  individual  cases,  (i)  Infection  may  reach 
the  gall-bladder  in  three  ways  (cf.  "Inflammation"  at  the  begin- 
ning of  this  section),  (a)  Ascending  infection  through  the  common 
and  the  cystic  ducts  accounts  for  the  etiologic  importance  of  duod- 
neal  catarrh  and  ulcer  in  the  formation  of  gall-stones,  (b)  In  des- 
cending infection  the  bacteria  descend  with  the  bile  from  the  liver, 
to  which  they  are  carried  by  the  hepatic  artery  in  general  bactere- 
mia; or,  more  frequently,  by  the  portal  vein  from  the  intestine  in 
constipation  (colon  bacillus),  or  from  infective  lesions  in  the  area 
drained  by  this  vein,  notably  appendicitis  and  inflammatory  proc- 
esses in  the  female  pelvis,  (c)  In  what  may  be  termed  direct 
hematogenous  infection  the  microorganisms  pass  through  the  cystic 
artery,  and  are  deposited  in  the  walls  of. the  gall-bladder.  Infection 
can  reach  the  gall-bladder,  by  one  or  all  of  the  routes  just  mentioned, 
in  intestinal  diseases  associated  with  bacteremia,  e.g.,  typhoid  fever, 
which,  not  infrequently,  is  complicated  by  cholecystitis  and  followed 
by  gall-stones.  No  matter  what  the  source  of  infection,  catarrhal 
inflammation  produces  an  increased  flow  of  mucus  and  desquamation 
of  the  epithelial  cells,  the  protoplasm  of  which  degenerates  and 
forms  cholesterin,  which  may  unite  with  other  constituents  of  the 
bile  (bilirubin,  calcium  salts)  in  varying  proportions  (vida  infra). 
(2)  Biliary  stasis  may  be  due  to  obstruction,  the  causes  of  which 
are  listed  under  "Inflammation"  at  the  beginning  of  this  section. 
In  other  cases  the  bile  stagnates  or  flows  slowly  because  of  defective 
propulsion.  Pericystic  adhesions  and  inflammatory  rigidity  of  the 
walls  of  the  gall-bladder  interfere  with  its  contractions.  Senescence 
probably  weakens  the  muscular  coat  of  the  gall-bladder;  patients 


782  MANUAL    OF    SURGERY 

coming  to  operation  are  usually  over  forty.  Sedentarj^  habits, 
tight  lacing,  and  large  abdominal  tumors,  including  the  pregnant 
uterus,  all  hinder  abdominal  respiration,  hence  the  free  flow  of  bile; 
these  conditions,  with  the  greater  frequency  in  women  of  con- 
stipation, pelvic  infections,  and  ptosis  of  the  liver  and  kidney, 
which  may  kink  the  cystic  or  common  ducts,  explain  why  75  per  cent. 
of  the  patients  are  female.  Pregnancy  not  only  favors  biliary  stasis, 
but  is  associated  with  hypercholesterinemia.  and  may  be  followed 
by  infection,  consequently  90  per  cent,  of  these  female  patients  have 
borne  children.  (3)  Hypercholesterinemia  may  result  from  faulty 
metabolism,  excess  of  meat.  fat.  eggs,  and  fish  in  the  diet  (hence  the 
patients  are  usually  stout),  pregnancy,  lactation,  syphilis,  tuber- 
culosis, nephritis,  diabetes,  arteriosclerosis,  malignant  tumors,  and 
acute  infectious  diseases.  Those  who  put  most  emphasis  on  the 
importance  of  an  increased  amount  of  cholesterin  (cholesterol)  in 
the  blood  and  the  bile  think  that  inflammation  is  more  often  the 
result  than  the  cause  of  gall-stones.  It  is  true  that  in  more  than 
50  per  cent,  of  the  operations  for  cholelithiasis,  the  contents  of 
the  gall-bladder  are  sterile,  but  in  many  of  these  the  bacteria  orig- 
inally present  have  disappeared,  lea\'ing  the  stones. 

The  stones  are  almost  always  formed  in  the  gall-bladder,  seldom 
in  the  biliary  ducts,  although  they  may  be  transported  to  the  latter 
situation.  The  nucleus  of  a  stone,  when  present,  is  generally  a 
mass  of  bacteria  or  desquamated  epithelial  cells,  rarely  a  blood  clot 
or  other  foreign  body.  There  may  be  a  single  stone  or  many 
hundreds  of  stones.  When  multiple  they  are  faceted  from  mutual 
pressure.  The  size  varies  from  that  of  a  scarcely  visible  particle 
up  to  that  of  a  goose  egg.  They  are  composed  of  cholesterin, 
calcium  salts,  or  bile  pigments,  or,  more  often,  of  various  com- 
binations of  these  substances.  Five  forms  may  be  noted,  (i)  The 
cholesterin-hiliruhin-calcium  stones  with  the  cholesterin  predominat- 
ing, are  those  usually  found  in  the  gall-bladder.  They  are  often 
soft  and  friable,  and  may  be  round  (if  single) ,  tetrahedral,  or  pre- 
senting multiple  facets.  A  barrel-shaped  concretion  may  be  formed 
in  the  ducts.  The  appearance  varies  with  the  constituents.  If 
there  is  a  shell  of  cholesterin  the  stone  is  smooth,  grey,  pearly,  and 
shining;  if  of  bilirubin-calcium,  greenish-brown;  if  of  carbonate  of 
calcium,  hard,  white,  and  smooth  or  nodulated.  On  section  the 
stone  shows  alternating  light  and  dark  concentric  laminae.  There 
is  often  a  soft  and  greasy  nucleus.  Stones  of  this  sort  are  said  to 
occur  when  infection  is  the  primary  cause.  (2)  Pure  cholesterin 
stones  are  found  chiefly  in  the  gall-bladder  and  common  duct.     They 


ABDOMEN  783 

are  greasy,  light  in  weight,  round  or  oval,  smooth  or  nodular,  clear 
or  slightly  yellowish,  moderately  soft,  and  almost  translucent. 
The  cut  surface  glistens  and  shows  radiating  striations.  These 
calculi  are  the  result  of  obstruction,  grow  slowly,  and  may  take 
years  to  reach  the  size  of  a  cherry.  (3)  Pure  hiliruhin-calcium 
stones  are  dark  green  or  black,  hard,  nodular,  occasionally  spiculated, 
often  numerous,  and  seldom  larger  than  a  pea.  They  are  usually 
formed  in  the  smaller  ducts  of  the  liver.  (4)  Pure  calcium  carbonate 
stones  (small,  white,  hard,  heavy,  and  nodular)  and  (5)  pure  bilirubin 
stones  (small,  friable,  round  or  angular,  yellow,  green,  or  black, 
and  light  in  weight)  are  very  rare. 

The  symptoms  vary  with  the  position  of  the  stones  and  the 
condition  of  the  biliary  apparatus,  and  these  variations  will  be 
described  after  a  general  consideration  of  the  clinical  features  of 
cholelithiasis.  The  symptoms  are  caused  by  inflammation  or 
obstruction,  or  both.  The  most  important  local  symptoms  of 
inflammation  are  pain,  tenderness,  and  rigidity  of  the  upper  right 
rectus;  the  general  symptoms,  those  of  sepsis.  The  chief  local 
symptoms  brought  about  by  obstruction  are  pain,  tenderness,  and 
swelling  of  the  gall-bladder,  liver,  pancreas,  and  indirectly  the 
spleen;  the  general  changes,  those  of  jaundice.  Reflex  gastro- 
intestinal disturbances  may  be  due  to  either  inflammation  or  ob- 
struction in  the  biliary  tract.  Biliary  colic  is  caused  by  acute 
transient  obstruction  of  one  of  the  ducts,  usually  the  result  of  the 
passage  or  the  attempted  passage  of  a  stone  or  plug  of  mucus,  but 
sometimes  the  result  of  other  causes,  e.g.,  inflammatory  sw^elling 
of  the  mucosa,  parasites,  distension  of  the  duodenum,  and  kinking 
of  the  ducts  from  adhesions  or  ptosis  of  the  liver  or  the  kidney. 
In  a  severe  case  there  is  sudden  excruciating  pain  in  the  epigastrium 
or  the  right  hypochrondrium,  which  radiates  to  the  back  and  the 
right  shoulder,  and  is  accompanied  by  vomiting,  sweating,  and 
sometimes  collapse.  Death  is  possible,  but  rare.  Intestinal  paraly- 
sis is  an  occasional  concomitant.  The  attack  lasts  from  a  few  hours 
to  several  days,  the  pain  leaving  as  suddenly  as  it  came,  if  the  stone 
passes  or  which  is  more  frequent,  drops  back  into  the  gall-bladder. 
Gradual  onset  and  slow  subsidence  indicate  a  lodged  stone. 
Jaundice  may  follow  in  from  12  to  24  hours  or  longer,  from  the 
passage  of  the  calculus  through,  or  its  retention  in,  the  common 
duct,  or  from  inflammatory  obturation  of  this  canal.  Typical 
biliary  colic  occurs  in  about  25  per  cent,  of  the  cases  of  cholelithiasis. 
Between  the  attacks  there  may  be  complete  relief;  or,  if  there  is  a 
lodged  stone  or  a  chronic  cholecystitis,  dull  pain  radiating  from 


784  MANUAL   OF    SURGERY 

the  right  hypochondrium  to  the  epigastrium,  around  to  the  back 
and  up  to  the  right  scapula.  In  these  cases  tenderness  may  be 
elicited  between  the  ninth  costal  cartilage  and  the  umbilicus 
(Robson's  point.  Fig.  376),  or  by  pressing  the  hand  well  up  beneath 
the  right  costal  arch  and  asking  the  patient  to  take  a  full  breath, 
which  is  abruptly  checked  by  acute  discomfort.  The  gall-bladder, 
when  enlarged  and  distended,  may  be  felt  immediately  below  the 
ninth  costal  cartilage,  or,  if  the  liver  is  enlarged,  at  a  lower  point. 
The  swelling  is  smooth,  oval,  tense,  and  moves  with  respiration; 
dulness  on  precussion  is  seldom  present  unless  the  tumor  is  very 
large.  Gall-stone  crepitus  on  manipulation  of  the  gall-bladder  is  a 
surgical  curiosity.  Jaundice  is  a  symptom  of  cholelithiasis  in  only 
20  per  cent,  of  the  cases.  The  color  of  the  skin  varies  with  the 
degree  of  the  obstruction,  from  a  light  lemon  yellow  in  catarrhal 
jaundice,  to  a  deep  olive  or  bronzed  hue  in  chronic  complete  oc- 
clusion of  the  choledochus.  Recurring  jaundice  is  produced  by 
only  two  diseases,  cholelithiasis  and  chronic  pancreatitis,  and  in 
the  latter  the  icterus  is  generally  remittent  rather  than  intermittent. 
The  important  phases  of  obstructive  jaundice  from  a  surgical  stand- 
point are  its  effects  on  the  gall-bladder  (vide  infra) ,  the  liver  (swell- 
ing, cirrhosis,  degeneration,  and,  if  there  is  infection,  cholangitis, 
and  possibly  abscess),  the  pancreas  (pancreatitis),  the  spleen  (en- 
largement secondary  to  hepatic  cirrhosis),  the  kidneys  (choluria. 
cholemic  nephritis,  although  the  latter  is  probably  due  more  to 
infection  than  to  the  elimination  of  bile),  the  stools  (clay  colored 
from  lack  of  bile  and  increase  of  fat),  and  the  blood  (spontaneous 
bleeding,  difficult  and  uncertain  hemostasis  after  operation, 
cholemia).  Cholemia  refers  to  the  toxic  effects  of  icterus.  The 
clinical  features  are  somewhat  similar  to  those  of  acute  yellow 
atrophy  of  the  liver.  The  patient  has  a  dry  tongue  and  fever, 
becomes  stupid  or  delirious,  and  succumbs  in  coma,  occasionally 
preceded  by  convulsions.  In  many  of  the  cases,  however,  the  cause 
of  the  symptoms  is  a  mixed  one.  since  there  are  at  least  three  sources 
for  the  toxemia,  the  liver  (cholemia) ,  the  kidneys  (uremia) ,  and  the 
infection  (septic  intoxication  or  septicemia),  the  last  of  which  is, 
in  itself,  capable  of  producing  hemolysis  and  jaundice.  The  gas- 
trointestinal symptoms  are  indigestion,  pylorospasm,  cardiospasm 
(vide  infra),  and  intestinal  paralysis  from  biliary  colic  (vide  sapra) 
or  peritonitis.  Gall-stone  ileus  has  been  described  under  "  Intestinal 
Obstruction. "  Examination  of  the  stomach  contents  may  reveal  hy- 
perchlorhydria,  but  in  many  cases  the  amount  of  hydrochloric  acid  is 
normal  or  below  normal.     By  means  of  the  duodenal  tube  Lyon  aspi- 


ABDOMEN  785 

rates  the  contents  of  the  duodenum  which  can  then  be  studied  chem- 
ically, bactcriologically,  and  eytologically.  Visible  bile  cannot  be 
recovered  from  the  fasting  duodenum.  If  100  c.c.  of  a  25  per  cent, 
solution  of  magnesium  sulphate  are  injected  through  the  tube  the 
common  duct  sphincter  relaxes  and  the  gall-bladder  contracts,  after 
which  the  first  specimen  of  bile  obtained  comes  from  the  common 
duct,  the  second  from  the  gall-bladder,  and  the  third  from  the  liver. 
In  choledochitis  and  cholecystitis  the  bile  is  viscid  from  an  excess  of 
mucus,  turbid  from  pus  and  epithelial  cells,  and  contains  bacteria. 
In  cholelithiasis  there  may  be,  in  addition,  crystals  of  bile  salts 
(Lyon).  The  blood  may  show  a  leukocytosis  (in  infection),  an 
increase  in  the  coagulation  time  (in  jaundice),  or  hypercholesterin- 
emia.  An  increase  in  the  cholesterol  content  of  the  blood,  i.e., 
above  200  m.g.  in  100  c.c. ,  occurs  in  so  many  conditions,  other  than  gall- 
stones (vide  supra) ,  that  the  value  of  this  test  is  much  impaired .  The 
urine  may  show  bile  (in  jaundice)  or  albumen  and  casts  (in  nephritis) . 
The  stools  are  clay  colored  in  duct  obstruction,  because  of  the  lack 
of  bile  and  an  increase  of  fat.  Sometimes  a  gall-stone  is  found; 
if  faceted  it  indicates  that  other  stones  have  been  or  are  in  the 
biliary  tract.  The  X-ray  density  of  gall-stone  shadows  depends 
upon  the  amount  of  calcium  salts  present.  A  ring  like  shadow 
indicates  a  calculus  with  a  shell  of  calcium  salts.  Pure  cholesterin 
stones  are  less  dense  than  the  bile  and  give  the  same  appearance 
as  bubbles  of  air.  A  thick  walled  gall-bladder  or,  after  a  barium 
meal,  an  internal  fistula  can  sometimes  be  demonstrated  in  a  skia- 
gram. Owing  to  the  number  of  cases  (50  per  cent.)  in  which  the 
stones  do  not  show,  X-ray  examination  in  cholelithiasis  is  of  value 
chiefly  to  exclude  other  conditions,  e.g.,  renal  calculi,  gastric  or 
duodenal  ulcer.  The  clinical  features  of  cholelithiasis  vary  according 
to  the  state  of  the  bihary  tract,  and  particularly  according  to  whether 
the  calcuH  are  in  (i)  the  gall-bladder,  (2)  the  cystic  duct,  (3)  the 
upper  or  (4)  lower  common  duct,  or  (5)  the  hepatic  duct. 

I.  Stones  in  the  gall-bladder  (a)  without  symptoms  may  occur, 
so  long  as  there  is  no  inflammation  or  obstruction.  However,  the 
number  of  such  cases,  at  one  time  thought  to  be  large,  is  diminishing 
rapidly  since  so-called  digestive  disturbances  are  more  often  investi- 
gated by  operation,  (b)  Chronic  cholecystitis,  with  or  without  calculi, 
gives  rise  to  "qualitative  food  dyspepsia,"  which  occurs  after  eating 
fatty  and  gas-producing  foods.  Thus  the  common  duct  may  be 
compressed  by  the  distended  duodenum,  and  the  subsequent  expan- 
sion of  the  gall-bladder  causes  pain  (C.  H.  Mayo).  Physiologic 
dilatation  of  the  gall-bladder,  owing  to  the  increased  secretion  of 


786  MANUAL    OF    SURGERY 

bile  after  meals,  also  may  cause  distress.  Reflex  pylorospasm  leads 
to  vomiting  which  relieves  the  pain.  Cardiospasm  is  much  less 
frequent.  Severe  bihary  colic  is  generally  due  to  stones,  mild  colic 
from  the  passage  of  plugs  of  mucus  or  thick  bile.  In  about  one-third 
of  the  cases  of  chronic  cholecystitis,  calculi  are  absent.  Pericystic 
adhesions,  likewise,  may  cause  colic  after  distension  of  the  gall 
bladder,  or,  according  to  their  attachments,  after  distension  of  the 
stomach,  duodenum,  or  colon.  W.  J.  Mayo  states  that  in  simple 
gall-stone  colic  the  pain  is  felt  in  the  epigastrium,  and  that  pain  in  the 
region  of  the  gall-bladder  is  an  indication  of  disease  of  the  walls  of 
this  viscus;  when  this  occurs  the  patient  does  not  obtain  complete 
rehef  between  attacks.  Tenderness  can  almost  always  be  elicited 
over  the  gall-bladder,  which  is  sometimes  covered  by  a  linguiform 
projection  of  the  anterior  edge  of  the  liver  (Riedel's  lobe).  Remote 
lesions,  like  endocarditis  and  arthritis,  have  been  attributed  to 
chronic  cholecystitis.  The  disease  may  be  confused  with  gastric  or 
duodenal  ulcer,  intestinal  colic,  chronic  appendicitis,  floating  kidney, 
and  epigastric  hernia,  (c)  Carcinoma  of  the  stone-containing  gall- 
bladder is  hard,  uneven,  and  only  slightly  painful.  There  are  at 
first  digestive  disturbances,  and,  later,  cachexia,  and  jaundice  and 
ascites  from  invasion  of  the  portal  glands. 

2.  Stone  in  the  cystic  duct  or  pelvis  of  the  gall-bladder,  causing 
obturation,  may  be  associated  with  (a)  acute  cholecystitis,  (b)  empy- 
ema, (c)  gangrene,  or  (d)  hydrops,  (a)  Acute  cholecystitis  (catarrhal 
and  interstitial)  is  accompanied  by  pain,  tenderness,  and  muscular 
rigidity  in  the  region  of  the  gall-bladder,  which  is  distended  and  often 
palpable.  Vomiting  and  constipation  are  usually  present.  Jaun- 
dice may  occur  from  extension  of  the  inflammation  to  the  other  ducts, 
or  from  the  pressure  of  a  large  stone  or  lymph  gland  on  the  common  or 
the  hepatic  duct.  There  is  fever  with  leukocytosis.  The  disease  is 
most  often  confounded  with  acute  appendicitis,  occasionally  with 
one  of  the  other  conditions  resembling  appendicitis  (q.  v.).  (b)  In 
empyema  of  the  gall-bladder  the  symptoms  are  the  same  in  kind  but 
of  greater  degree.  Palpation  of  the  gall-bladder  may  be  impossible 
owing  to  the  muscular  rigidity.  Perforation,  with  pericystic  abscess, 
is  usually  not  diagnosticated  before  operation.  Perforation  into  the 
free  peritoneal  cavity  causes  a  generalized  peritonitis  with  biHous 
ascites.  Bilious  ascites  without  a  discoverable  leak  in  the  biliary 
tract  has  been  attributed  to  a  microscopic  perforation,  a  perforation 
that  has  closed,  rupture  of  the  intrahepatic  ducts,  postperitoneal 
rupture  of  the  common  or  the  hepatic  duct,  with  subsequent  rupture 
into  the  peritoneum,  or  to  filtration  of  the  bile  through  the  walls  of  the 


ABDOMEN  787 

gall-bladder  or  ducts  (Buchanan),  (c)  Gangrene  may  be  suspected 
if  the  pain  suddenly  abates  and  the  other  symptoms  persist  and  grow 
worse,  but  as  a  rule  the  condition  cannot  be  differentiated  symptoma- 
tologically  from  empyema,  (d)  Hydrops  cystidis  felleae  may  present 
no  symptoms  except  the  tumor.  However,  pain  and  Riedel's  lobe 
may  be  in  evidence.  The  swelling  may  be  mistaken  for  a  floating 
kidney  or  a  renal  tumor,  especially  hydronephrosis,  which  may  be 
globular  and  give  no  urinary  changes.  An  enlarged  gall-bladder  is 
more  movable  from  side  to  side,  immediately  returns  when  depressed 
toward  the  back,  merges  with  the  liver,  both  on  percussion  and  palpa- 
tion, and  does  not  extend  through  to  the  loin.  The  upper  end  of  a 
renal  tumor  can  often  be  felt  and  the  hand  pushed  in  between  the 
kidney  and  the  liver.  The  kidney  springs  from  the  loin  and  is 
crossed  by  a  band  of  tympany  (colon).  Further  differentiation  is 
often  possible  by  means  of  the  ureteral  catheter  and  pyelography. 
3.  Stone  in  the  upper  common  duct  causes  (a)  acute  or  chronic 

(b)  incomplete  or  complete  obstruction,  (a)  Acute  transient  obstruc- 
tion produces  typical  biliary  colic,  with  transient  jaundice,  (b) 
Chronic  obstruction  due  to  stone  is  usually  incomplete  and  often  inter- 
mittent, hence  the  jaundice  varies  in  intensity  in  different  individuals 
and  frequently  in  the  same  individual.  The  color  is  yellow  and 
never,  as  in  malignant  occlusion,  olive  green  or  deep  brown.  Accord- 
ing to  Mayo  about  30  per  cent,  of  the  patients  are  without  jaundice 
when  they  come  under  observation.  The  pain  and  tenderness  are 
near  the  middle  line.  Chills,  followed  by  high  fever,  and  sweating 
[Charcot^  s  intermittent  fever)  occur  at  irregular  intervals,  owing  to  an 
increase  in  the  cholangitis  induced  by  movements  of  the  calculus  or 
temporary  inflammatory  obturation.  Emaciation  is  often  a  promi- 
nent feature.  The  liver  and  sometimes  the  spleen  are  enlarged. 
The  ducts  above  the  obstruction  dilate,  and  may  become  varicose 
or  form  cystic  diverticula.  Such  cysts,  when  in  the  extra  hepatic 
ducts  or  when  presenting  on  the  surface  of  the  liver,  may  rupture, 
causing  a  bilious  ascites  (vide  supra).  Rarely  does  a  cyst  of  this 
character  attain  a  large  size,  although  an  enormous  dilatation  of  the 
biliary  passages,  forming  a  cavity  the  size  of  a  child's  head,  has  been 
reported.  The  gall-bladder  is  at  first  distended,  but  later,  in  80 
per  cent,  of  the  cases,  it  grows  smaller  and  smaller,  because  of  chronic 
inflammation,  and  because  the  obstruction  is  often  incomplete  or 
intermittent  and  the  bladder  is  constantly  contracting  to  empty  itself. 

(c)  Complete  obstruction  is  almost  always  due  to  tumor,  generally  a 
carcinoma  of  the  pancreas  or  the  stomach.  However,  stricture 
from  gall-stone  ulceration  or  choledochotomy  and  accidental  ligation 


788  MANUAL   OF    SURGERY 

of  the  common  duct  during  a  cholecystectomy  sometimes  occur. 
Obstruction  due  to  carcinoma  presents  a  marked  contrast  to  that  due 
to  stone.  In  the  former  there  is  persistent  deep  green  or  brown 
jaundice,  with  no  fever,  and  slight  pain.  The  gall-bladder  is  usually 
distended,  whereas  in  chronic  stone  obstruction  it  is  usually  shrunken 
{Courvoisier's  hvw). 

4 .  Stone  in  the  lower  common  duct  presents  the  same  symptoms 
as  in  the  upper  common  duct,  except  that  pancreatic  involvement 
is  much  more  likely  to  occur.  A  stone  in  the  ampulla  of  Vater  may 
cause  pancreatic  stasis,  and  regurgitation  of  infected  bile  into  the 
pancreatic  duct;  in  the  pancreatic  segment  of  the  choledochus,  pan- 
creatic retention  from  pressure  on  the  canal  of  Wirsung.  The 
diseased  pancreas  itself  may,  in  turn,  compress  and  occlude  the  com- 
mon duct. 

5.  Impaction  of  a  stone  in  the  hepatic  duct  is  very  rare.  The 
symptoms  are  identical  with  those  of  occlusion  of  the  common  duct 
except  that  the  gall-bladder  is  never  distended. 

All  of  the  important  complications  of  cholelithiasis,  except  pneu- 
monia and  pleural  empyema,  have  been  mentioned  above. 

The  treatment  of  hepatic  colic  is  the  application  of  heat  and  the 
subcutaneous  administration  of  morphin  and  atropin.  For  the 
medical  treatment  of  cholelithiasis  the  reader  is  referred  to  a  text- 
book on  medicine.  Gall-stones  are  unaffected  by  drugs  and  the  aim 
of  the  physician  is  to  cure  the  catarrhal  inflammation  and  prevent 
the  formation  of  other  stones.  Medical  treatment  is  indicated 
in  cases  in  which  operation  would  be  too  dangerous  because  of  the 
presence  of  some  independent  affection.  In  all  other  cases  surgical 
treatment  should  be  advised.  In  the  early  stages  removal  of  the 
stones  is  easy  and  safe;  after  the  development  of  complications,  both 
the  difhculties  and  the  danger  are  vastly  increased. 

Operations  on  the  biliary  passages  are  greatly  facihtated  by 
placing  a  sand  bag  beneath  the  spine,  in  order  to  push  the  liver  and 
ducts  forward  and  allow  the  intestines  to  fall  away  from  the  field  of 
operation.  In  the  presence  of  chronic  jaundice  there  is  great  danger 
of  persistent  and  uncontrollable  hemorrhage.  In  order  to  avert  this 
catastrophy,  the  patient  may  be  given  blood  by  transfusion,  or 
horse  serum  hypodermatically;  Robson  advises  the  oral  administra- 
tion of  30  grains  of  calcium  chlorid  daily  for  several  days  preceding 
operation,  and  60  grains  per  rectum  for  a  few  days  after  operation. 
The  same  author  opens  the  abdomen  through  the  middle  of  the  right 
rectus  muscle,  continuing  the  incision  upwards  and  inwards  along  the 
costal  margin  as  far  as  the  ensiform  if  more  room  is  desired.     Perthes 


ABDOMEN  789 

gains  a  wide  exposure,  at  the  same  time  preserving  the  nervous 
supply  to  the  rectus,  by  making  an  incision  close  to  the  median  line 
from  the  cnsiform  nearly  to  the  umbilicus,  thence  outward  at  right 
angles  as  far  as  the  costal  margin.  In  order  to  prevent  retraction 
the  rectus  muscle  is  tastened  to  its  anterior  sheath  before  division, 
and  the  rectangular  musculocutaneous  flap  turned  up  from  the  pos- 
terior sheath  and  the  peritoneum,  which  are  opened  by  an  oblique 
incision.  The  stomach,  the  duodenum,  the  liver,  the  pancreas,  and 
the  appendix  should  be  palpated,  unless  by  so  doing  there  is  danger 
of  disseminating  infection.  After  packing  off  the  stomach  and 
intestines,  and  separating  any  adhesions  which  may  be  present, 
the  gall-bladder  and  cystic  duct  may  be  investigated,  and  a  finger 
passed  through  the  foramen  of  Winslow,  in  order  to  explore  the 
supraduodenal  segment  of  the  common  duct.  The  rest  of  the 
operation  depends  upon  (i)  the  local  conditions  found  and  (2)  the 
general  state  of  the  patient. 

The  indications  for  cholecystostomy  and  cholecystectomy  are 
much  debated,  hence  the  statements  made  below  do  not  agree  with 
the  conclusions  of  all  teachers. 

I.  The  local  condition  of  {a)  the  gall-bladder  influences  the  decision 
considerably  with  many  surgeons.  Since,  in  the  absence  of  complica- 
tions, the  mortality  of  the  two  operations  is  almost  equal,  and  after 
cholecystectomy  the  convalescence  is  quicker  and  smoother,  and  the 
recovery  much  more  likely  to  be  permanent,  we  remove  the  gall- 
bladder in  all  cases  in  which  the  disease  is  confined  to  this  viscus, 
unless  the  difficulties  of  the  operation  promise  to  be  so  great  as  to 
cancel  its  normal  superiority  over  cholecystostomy.  If  the  symp- 
toms are  those  of  cholecystitis  and  the  gall-bladder  looks  normal,  it 
should  be  excised,  if  the  lymph  glands  along  the  ducts  are  enlarged 
and  there  is  no  lesion  in  the  stomach,  the  duodenum,  or  the  pancreas 
to  account  for  the  lymphadenitis.  We  have  sutured  a  stab  wound  of 
the  gall-bladder,  but  in  a  severe  laceration  would  probably  perform 
cholecystectomy,  (b)  Obstruction  of  the  cystic  duct  from  any  cause 
demands  cholecystectomy,  unless  the  patient  is  very  ill,  when  a  quick 
cholecystostomy  should  be  performed,  and  the  gall-bladder  removed 
after  the  patient  has  regained  strength,  (c)  In  biliary  fistula  follow- 
ing injury  to  the  common  duct,  and  in  irremovable  obstruction  to  the 
choledochus,  e.g.,  from  carcinoma,  chronic  pancreatis,  cicatricial 
stricture,  or  rarely  calculus,  the  bile  may  be  diverted  through  the 
gall-bladder  to  the  skin,  the  stomach,  or  the  intestine.  In  chole- 
dochotomy  the  gall-bladder  is  of  service  in  drawing  up  the  common 
duct,  and,  if  drained,  reduces  the  tension  on  the  suture  line  in  the 


790 


MANUAL   OP    SURGERY 


duct.  If  the  common  duct  is  drained  instead  of  sutured,  and  a 
cholecystectomy  then  performed,  there  is  more  risk  of  dislodging 
the  tube  in  the  common  duct  and  soiling  the  peritoneum.  However, 
in  many  of  these  cases  we  prefer  cholecystectomy  to  cholecystostomy. 
In  performing  cholecystectomy  one  must  be  sure  the  common  duct  is 
patent,  or  can  be  made  so.  (d)  In  suppurative  cJiolangitis  the  gall- 
bladder and  the  common  duct  should  be  drained,  (e)  Acute  pan- 
creatitis demands  cholecystostomy.  In  chronic  pancreatitis  with 
jaundice  the  bile  may  be  diverted  as  in  irremovable  obstruction  to 
the  choledochus.  In  chronic  pancreatitis,  with  gall-bladder  disease 
and  without  jaundice,  cholecystectomy  may  be  performed. 

2.  If  the  patient  is  in  poor  condition 
from  any  cause,  e.g.,  age,  sepsis,  or  an  in- 
dependent affection,  cholecystostomy 
should  be  chosen  rather  than  cholecystec- 
tomy. When  gall-stones  are  discovered 
during  a  laparotomy  for  some  other  condi- 
tion, according  to  the  nature  of  the  condi- 
tion and  the  general  state  of  the  patient, 
the  gall-bladder  may  be  drained  or  removed. 
In  cholecystostomy  the  gall-bladder  is 
drawn  into  the  wound,  aspirated,  an  incision 
made  in  the  fundus,  and  the  stones  removed 
with  the  linger,  forceps,  or  a  scoop.  A 
rubber  tube  is  sutured  in  the  gall-bladder 
with  catgut,  the  edges  of  the  gall-bladder 
inverted  around  the  tube  by  depressing  it, 


Fig.  443.- — A.  Mattress  su- 
ture   everting    the    skin.      B. 

f  jr  "r5  r  ""uSt'  and  a  purse-string  suture  applied  to  maintain 


the  edges  of  the  gall-bladder. 

C.  Suture  through  the  tube  the  inversion,   thus  making  a  tight  joint. 

and  the  gall-bladder.  ,     .  n      1        .  . .  ,  r 

It  is  well  also  to  pass  a  mattress  suture  oi 
catgut  through  the  skin  around  the  tube,  so  as  to  prevent  inversion 
of  the  cutaneous  margin  on  which  the  tube  rests  (Fig.  443).  The 
tube  should  be  long  enough  to  drain  into  a  receptacle  at  the  side 
of  the  bed.  When  the  catgut  has  been  absorbed  the  tube  is  ready 
to  be  removed.  The  mortality  of  cholecystostomy  for  gall-stones 
is  I  to  2  per  cent.  The  biliary  fistula  left  after  removing  the  tube 
should  close  spontaneously.  A  persistent  fistula  discharging  bile 
is  due  to  obstruction  of  the  common  duct;  discharging  mucus  to 
blocking  of  the  cystic  duct;  in  either  case  a  secondary  operation 
is  required.  In  former  days  a  biliary  fistula  sometimes  followed 
suturing  of  the  gall-bladder  to  the  skin. 

Cholecystectomy  is  preceded  by  aspiration  of  the  gall-bladder, 


ABDOMEN  791 

if  it  is  much  distended.  The  gall-bladder  and  the  anterior  edge  of  the 
liver  are  pulled  downward,  rotated  outward  through  the  wound, 
and  held  by  an  assistant,  thus  making  taut  the  hepatoduodenal 
ligament,  which  is  further  exposed  by  drawing  up  the  neck  of  the 
gall-bladder  with  forceps,  opened  by  a  small  incision,  and  the  cystic 
duct  isolated,  clamped  with  forceps,  ligated  below  the  forceps,  and 
divided  between  the  forceps  and  the  ligature.  The  cystic  artery  is 
next  treated  in  the  same  manner.  The  common  duct  should  be  seen, 
otherwise  there  is  danger  of  ligating  or  cutting  it.  The  peritoneal  re- 
flection from  the  liver  is  split  on  each  side  of  the  gall-bladder,  and  the 
gall-bladder  removed  from  within  outwards  by  blunt  dissection.  The 
peritoneal  flaps  are  then  stitched  together,  any  oozing  from  the  liver 
being  checked  by  sutures  or  gauze  packing.  If  bleeding  is  controlled 
absolutely,  drainage  may  be  omitted.  If  drainage  of  the  biliary 
apparatus  is  required,  the  cystic  artery  alone  may  be  ligated,  and  a 
rubber  tube  sutured  to  the  end  of  the  open  cystic  duct  with  catgut, 
or  a  choledochotomy  may  be  performed.  The  mortality  of  chole- 
cystectomy for  uncomplicated  gall-stones  is  from  i  to  2  per  cent. 

Owing  to  the  action  of  the  sphincter  at  the  lower  end  of  the  chole- 
dochus  the  bile  is  normally  discharged  into  the  duodenum  intermit- 
tently, and  accumulates  in  the  gall-bladder  during  the  intervals. 
After  cholecystectomy  the  sphincter  continues  to  act  in  this  manner, 
and  the  extrahepatic  ducts  dilate  until  they  contain  as  much  bile  as 
the  gall-bladder,  or,  more  often,  until  the  sphincter  itself  becomes 
dilated  (Judd  and  Mann).  Thus  is  explained  the  dilatation  of  the 
choledochus  observed  also  after  obstruction  to  the  cystic  duct,  and 
the  dilatation  of  the  stump  of  the  cystic  duct  ("new  gall-bladder" 
that  is  sometimes  found  after  removal  of  the  gall-bladder). 

Cholecystogastrostomy  consists  in  the  formation  of  a  fistula 
between  the  gall-bladder  and  the  stomach;  cholecystenterostomy, 
between  the  gall-bladder  and  the  duodenum,  jejunum,  or  colon. 
These  operations  may  be  employed  in  biliary  fistula  depending  on 
stricture  or  other  permanent  occlusion  of  the  common  duct;  in 
cancer  of  the  head  of  the  pancreas  or  common  duct  leading  to  chronic 
jaundice;  in  chronic  pancreatitis  with  jaundice;  and  rarely  in  gall- 
stone impacted  in  the  ducts,  when  the  common  duct  cannot  be 
exposed  and  the  patient  is  in  no  condition  to  stand  a  prolonged 
operation.  The  operation  is  performed  by  means  of  the  Murphy 
button  or  by  simple  suturing  (vide  infra). 

Cysticotomy  is  incision  into  the  cystic  duct,  usually  for  the 
removal  of  a  calculus  which  cannot  be  pushed  backwards  into  the 
gall-bladder.     The  duct  may  be  sutured  with  catgut  or  drained  with 


792 


MANUAL   OF    SURGERY 


a  rubber  tube.     In  almost  all  cases  of  obstruction  to  the  cystic  duct 
cholecystectomy  is  the  better  operation. 

Choledochotomy  is  incisioni  nto  the  common  duct,  for  the  removal 
of  a  stone  {choledocholithotoniy) ,  or  for  the  purpose  of  drainage  in 
cholangitis.  When  the  stone  lies  in  the  supraduodenal  portion  of  the 
duct,  which  is  about  three-fourths  of  an  inch  in  length  and  runs  in  the 
right  edge  of  the  gastro-hepatic  omentum,  it  is  brought  forward  by  a 
finger  in  the  foramen  of  Wmslow.  The  portal  vein  and  hepatic 
artery  lie  to  the  left.  After  opening  the  hepatoduodenal  ligament, 
the  choledochus  is  incised  longitudinally,  the  stone  removed,  and  a 
finger  or  a  probe  passed  up  into  the  hepatic  duct  and  then  down  as 
far  as  the  duodenum,  to  make  sure  that  there  are  no  other  calculi. 
If  one  is  certain  that  no  stones  have  been  left  the  incision  in  the 
choledochus  may  be  closed,  and  a  small  gauze  drain  placed  in  the 
vicinity  of,  but  not  in  contact  with,  the  suture  line,  so  as  to  provide 
for  leakage,  should  it  occur.  The  sutures  may  be  inserted  before 
the  stone,  which  acts  as  a  guide,  is  removed.  If  the  stones  are  soft, 
friable,  or  multiple,  or  there  is  a  cholangitis,  a  rubber  drainage  tube 
should  be  passed  up  into  the  hepatic  duct,  sutured  with  catgut  to  the 
incision  in  the  choledochus,  and  the  superfluous  portion  of  the  wound 
in  the  common  duct  closed.  Crushing  of  the  stone  without  opening 
the  duct  (choledocholithotrity) ,  or  breaking  it  up  by  the  insertion  of  a 
needle,  is  unsatisfactory,  because  fragments  are  often  left  behind. 
Occasionally  a  stone  in  the  common  duct  may  be  manipulated  back 
into  the  gall-bladder;  it  should  never  be  forced  towards  the  duo- 
denum. The  retroduodenal  portion  of  the  common  duct  is  about 
two  inches  in  length,  runs  in  or  on  the  pancreas,  and  cannot  be 
palpated  without  loosening  the  duodenum  and  turning  it  inwards. 
Stones  in  this  situation  may  be  removed  by  an  incision  in  the  upper 
portion  of  the  duct,  or,  when  occupying  the  lower  third  of  the  chole- 
dochus, especially  if  impacted  in  the  diverticulum  of  Vater,  a  duo- 
deno-choledochotomy  may  be  performed.  The  anterior  wall  of  the 
duodenum  is  opened,  and  the  stone  removed  by  enlarging  the  papilla, 
or  by  incising  directly  down  upon  it  through  the  posterior  wall  of 
the  gut.  The  incision  in  the  anterior  wall  of  the  duodenum  is  then 
sutured;  it  is  not  necessary  to  place  sutures  in  the  posterior  wall. 
The  mortahty  of  choledochohthotomy  is  lo  per  cent. 

Hepaticotomy,  or  incision  into  the  hepatic  duct,  has  the  same 
indications  as  choledochotomy,  but  is  seldom  performed. 

According  to  the  situation  of  an  irremovable  obstruction  a 
fistula  may  be  estabhshed  between  an  incision  in  the  liver  and  the 
intestine   {hepaticocholangioenterostomy),   stomach   {cholangiogastros- 


ABDOMEN  793 

tomy),  or  skin  {cholangiostomy);  between  the  common  duct  and  the 
intestine  (liiolcdochocnicroslomy),  stomach  (choledocJwgastroslomy), 
or  skin  {cholcdochostomy);  or  between  the  gall-bladder  and  the 
intestine,  stomach,  or  skin  (vide  supra).  Operations  connecting 
the  biliary  apparatus  with  the  stomach  are  to  be  preferred  in  irremov- 
able obstruction,  since  the  bile  is  not  lost,  as  in  an  external  fistula; 
there  is  not  the  same  danger  of  ascending  infection  as  in  an  intestinal 
fistula;  and  the  bile  emptied  into  the  stomach  does  not  interfere  with 
digestion.  When  all  the  bile  escapes  externally  anorexia  and  emacia- 
tion may  occur;  in  these  cases  the  bile  can  be  collected  and  given  by 
mouth.  Eliot  mentions  the  possibility  of  osteoporosis  from  pro- 
longed excessive  loss  of  bile. 

Choledochoplasty,  or  the  reconstruction  of  the  common  duct, 
may  be  attempted,  instead  of  the  operations  just  described,  when 
the  irremovable  obstruction  is  benign,  e.g.,  a  cicatricial  stricture. 
Incision  of  the  stricture  is  only  of  temporary  benefit.  Excision  with 
end-to-end  anastomosis  is  probably  the  best  procedure,  when  appli- 
cable. A  new  duct,  can  be  built  with  fascia,  peritoneum,  omentum, 
or  with  a  flap  derived  from  the  gall-bladder,  stomach,  intestine,  or 
abdominal  skin.  A  rubber  tube,  to  be  covered  later  with  omentum, 
can  be  sutured  into  the  two  stumps  of  the  duct,  or  into  the  upper 
stump  and  the  duodenum  (Sullivan).  The  tube  finally  passes  into 
the  bowel  and  leaves  a  fistulous  tract.  A  T-shaped  tube,  or  a  tube 
that  gains  exit  through  a  vahiilar  opening  in  the  duodenum  may 
be  employed,  the  tube  being  withdrawn  when  the  process  of  repair  is 
nearly  completed.  An  external  biliary  fistula  can  be  dissected  free 
except  for  its  inner  attachment,  and  anastomosed  wdth  the  lower 
portion  of  the  duct,  the  stomach,  the  duodenum,  or  a  segment 
of  unilaterally  excluded  intestine.  It  has  been  suggested  that  an 
artificial  choledochus  might  be  made  by  transplanting  the  appendix, 
or  a  piece  ot  artery,  vein,  or  ureter. 

THE  PANCREAS 

For  injuries  of  the  pancreas  see  "Injuries  of  the  Abdomen." 
Pancreatitis  is  due  to  trauma,  hematogenous  infection  in  general, 
infective  diseases,  infection  from  contiguous  structuers,  and  most 
frequently  to  ascending  infection  by  way  of  the  duct,  as  the  result  of 
catarrhal  inflammation  of  the  duodenum  or  choleHthiasis.  Ob- 
struction of  the  duodenal  papilla  by  a  stone  may  cause  pancreatic 
stasis  and  regurgitation  of  infected  bile;  a  stone  lodged  in  the  pan- 
creatic segment  of  the  common  duct  may  compress  the  canal  of 


794  MANUAL   OF    SURGERY 

Wirsung  and  lead  to  pancreatic  retention,  thus  predisposing  to 
infection.  Archibald  says  the  primary  lesion  is  necrosis  of  the 
cells,  and  that  infection  is  secondary;  cultures,  excepting  of  frank 
abscesses,  are  usually  sterile.  He  thinks  the  conditions  for  the  pro- 
duction of  pancreatitis  are  a  chemical  change  in  the  bile,  resulting  in 
an  increase  of  its  salts;  and  a  rise  in  the  pressure  in  the  biliary  tract 
induced  by  hypersecretion,  or  by  spasm  of  the  common  duct  sphincter 
of  Oddi ;  this  spasm  may  be  due  to  hyperacidity,  neighboring  ulcers, 
or  sudden  blocking  of  the  cystic  duct  by  stone  or  inflammation 
(see  "Cholecystectomy")-  Although  the  disease  may  occur  at  any 
age,  it  is  most  common  during  or  after  middle  life.  Three  forms  are 
described,  the  acute,  the  subacute,  and  the  chronic. 

Acute  pancreatitis  is  associated  with  the  escape  of  pancreatic 
ferments  into  the  periductal  tissues.  The  trypsin  digests  the  walls  of 
the  blood  vessels  and  causes  bleeding  into  the  gland.  The  steapsin 
splits  the  fat  into  glycerin  and  fatty  acids,  the  former  being  absorbed, 
and  the  latter  precipitated  with  calcium  salts.  As  a  consequence 
there  are  small  yellowish-white  patches  (fat  necrosis)  in  and  on  the 
pancreas,  in  the  omentum  and  mesentery  and  occasionally  in  more 
remote  situations.  These  disseminated  areas  of  necrotic  fat,  which 
resemble,  superficially,  miliary  tubercles  or  metastatic  neoplastic 
nodules,  produce  a  peritonitis,  usually  aseptic,  occasionally  septic. 
The  symptoms  are  sudden  violent  epigastric  pain,  vomiting,  constipa- 
tion, sometimes  slight  jaundice,  frequently  distention  of  the  abdo- 
men, and  the  usual  signs  of  collapse.  Owing  to  the  widespread  fat 
necroses  there  may  be  tenderness  over  the  whole  abdomen  and  in  one 
or  both  loins.  Death  may  occur  in  from  twenty-four  hours  to  one 
week.  Acute  pancreatitis  may  be  mistaken  for  intestinal  obstruc- 
tion, perforation  of  the  stomach  or  duodenum,  acute  cholecystitis 
(which  it  may  accompany),  appendicitis,  acute  gastritis  the  result  of 
swallowing  irritant  poisons,  and  acute  infection  of  the  kidney.  The 
progress  of  the  disease  is  so  rapid  that  the  stools  and  the  urine  seldom 
show  distinctive  signs  of  pancreatic  insufficiency  (see  "Chronic 
Pancreatitis"). 

The  treatment  is  drainage.  The  abdomen  will  usually  be  opened 
in  the  median  line  above  the  umbilicus  for  exploration.  The  pan- 
creas may  be  exposed  by  tearing  through  the  gastrohepatic,  or, 
better,  the  gastrocolic  omentum.  A  gauze  drain  may  then  be 
inserted  into  the  lesser  peritoneal  cavity.  It  is  seldom  necessary  to 
tie  the  vessels  in  the  pancreas,  as  the  loss  of  blood  is  not  the  cause  of 
death.  The  pancreas  may  be  drained  also  by  an  incision  in  the  loin, 
preferably  the  left,  the  drain  gaining  exit  below  the  lower  pole  of  the 


ABDOMEN  795 

kidney.  Cholecystostomy  is  indicated  if  there  be  gall-stones  or 
cholecystitis.  A  few  patients  have  recovered  with  this  form  of 
treatment. 

Subacute  pancreatitis  is  such  from  the  beginning,  or  follows  the 
acute  form  if  the  patient  survives,  the  symptoms  at  first  being  much 
the  same  but  less  severe.  At  a  later  period  suppuration  {suppurative 
pancreatitis)  or  gangrene  {gangrenous  pancreatitis)  may  occur,  with 
septic  symptoms,  viz.,  chills,  fever,  sweats,  rapid  emaciation,  and 
frequently  diarrhea  with  foul  smelling  or  bloody  stools.  If  an 
abscess  forms,  the  sweUing  may  be  detected  in  the  epigastrium  or  in 
the  loin,  or  the  pus  may  gravitate  to  either  iliac  region.  The  progno- 
sis is  somewhat  less  gloomy  than  in  the  acute  form.  The  treatment 
is  drainage  by  one  of  the  routes  mentioned  above,  with  the  removal 
of  gall-stones  and  drainage  of  the  biliary  passages  if  there  be 
cholelithiasis. 

Chronic  pancreatitis  is  characterized  by  a  marked  increase  in  the 
connective  tissue,  which  causes  the  organ  to  become  large  and  hard. 
The  fibrosis  is  more  pronounced  between  the  lobules  {interlobular 
pancreatitis)  or  in  the  lobules  {interacinar  pancreatitis) ;  in  the  latter 
form,  which  is  less  common  than  the  interlobular  variety,  the  islands 
of  Langerhans  are  involved  and  glycosuria  is  present.  The  islands 
of  Langerhans  are  supposed  normally  to  manufacture  an  internal 
secretion  which  prevents  glycosuria.  The  symptoms  are  emaciation, 
pain  after  eating,  paroxysms  of  pain  and  vomiting,  and  tenderness 
in  the  epigastrium.  The  pain  radiates  to  the  interscapular  region 
and  towards  the  left  shoulder.  The  pancreatic  point  of  Desjardin, 
which  corresponds  with  the  duodenal  opening  of  the  canal  of  Wirsung, 
and  which  is  supposed  to  be  the  point  of  greatest  tenderness,  is 
situated  from  5  to  7  cm.  from  the  umbilicus  on  a  line  running  to  the 
right  axilla  (Fig.  376).  Intermittent  jaundice,  when  present,  may 
be  due  to  gall-stones;  persistent  or  remittent  jaundice,  to  the  pressure 
of  the  contracting  pancreatic  tissue  on  the  common  bile  duct.  Rarely 
is  it  possible  to  outline  the  pancreas  by  palpation.  The  urine  may 
contain  sugar  (if  the  islands  of  Langerhans  are  involved),  fat,  glycerin 
derivatives  (Cammidge's  test),  calcium  oxalate  crystals,  indican,  bile, 
or  leucin  and  tyrosin.  An  excess  of  fat  and  muscle  fiber  may  be 
demonstrated  in  the  feces,  which  are  sometimes  acid  and,  even  when 
bile  is  present,  grayish-white  in  color.  When  salol  is  administered 
by  mouth  it  is  not  decomposed,  and  carbolic  and  salicyluric  acids  do 
not  appear  in  the  urine  {SaJdi's  sign) .  In  most  cases  the  laboratory 
tests  for  pancreatic  insufficiency  are  negative,  and  in  many  the 
indurated  pancreas  is  discovered  only  during  a  routine  exploration 


796  MANUAL    OF    SURGERY 

in  the  course  of  an  abdominal  operation.  The  treatment  is  removal 
of  gall-stones,  if  present,  the  nature  of  the  procedure  depending,  as 
previously  stated,  on  the  situation  of  the  stones  and  the  condition  of 
the  patient.  However,  many  surgeons  insist  that  the  biliary  tract 
should  be  drained  for  a  much  longer  time  (one  to  three  months) 
than  after  operation  for  uncomplicated  cholelithiasis.  In  cases  of 
persistent  jaundice  due  to  chronic  pancreatitis  the  gall-bladder  may 
be  anastomosed  with  the  intestine,  or,  better,  with  the  stomach. 
Archibald  suggests  incision  of  the  common  duct  sphincter,  after 
duodenotomy. 

Pancreatic  calculi  are  formed  much  in  the  same  manner  as  gall- 
stones, and  pancreatic  colic  is  much  like  gall-stone  colic,  except  that 
the  pain  is  below  and  to  the  inner  side  of  the  gall-bladder  and  may  be 
reflected  to  the  left  shoulder.  Pancreatic  calculi  may  be  associated 
with  gall-stones  or  with  the  various  forms  of  pancreatitis,  and  some- 
times cause  a  retention  cyst  by  damming  up  the  secretion  of  the 
gland.     In  a  few  instancs  they  have  been  removed  by  operation. 

Tumors  of  the  pancreas  include  carcinoma,  sarcoma,  adenoma, 
and  syphiloma.  Primary  growths  are  rare.  Carcinoma  is  the 
most  frequent,  and  affects  chiefly  the  head  of  the  gland.  The  symp- 
toms are  indigestion,  epigastric  pain,  emaciation,  and  in  the  later 
stages  jaundice,  painless  swelling  of  the  gall-bladder,  enlargement  of 
the  liver,  and  the  appearance  of  a  tumor.  The  signs  of  interference 
with  the  functions  of  the  pancreas  already  mentioned  also  may  be 
found.  The  treatment  is  symptomatic,  although  it  detected  at  any 
early  period,  excision  would  be  indicated.  Cholecystogastrostomy 
or  cholecystenterostomy  is  sometimes  performed  for  the  jaundice. 

Pancreatic  cysts  are  uncommon,  generally  arise  after  middle  age, 
and  may  be  true  or  false.  True  cysts  arise  within  the  gland  and 
include  retention  cysts  (pancreatic  ranula),  congenital  cystic  disease, 
cystadenoma,  hydatids,  and  hemorrhagic  cysts.  Pseudocysts  are 
usuaUy  effusions  into  the  lesser  peritoneal  cavity,  the  result  of  injury 
or  inflammation,  but  may,  however,  communicate  with  the  pancreas 
and  contain  a  proteolytic  and  an  emulsifying  ferment.  The  symptoms 
are  indigestion,  vomiting,  and  frequently  epigastric  pain.  Other 
symptoms  are  due  to  pressure  on  environing  organs,  or  to  interference 
with  the  functions  of  the  pancreas,  such  as  have  already  been  men- 
tioned. The  patient  usually  emaciates  and  becomes  sallow  and 
weak.  When  of  large  size  the  cyst  reaches  the  abdominal  wall  be- 
tween the  stomach  and  the  colon,  although  it  may  be  above  the 
stomach  or  distend  the  layers  of  the  mesocolon.  It  is  usually  im- 
movable and   at   least  partly   covered  by  gastric  tympany.     The 


ABDOMEN  797 

treatment  in  suitable  cases  is  extirpation.  In  most  instances  this  is 
ini])t)ssiblc  because  of  adhesions,  and  the  cyst  is  sutured  to  the 
anterior  abdominal  wall  and  drained. 

THE  SPLEEN 

Splenoptosis  {wandering  or  movable  spleen)  is  usually  a  part  of 
Glenard's  disease,  or  is  caused  by  enlargement  of  the  spleen.  The 
symptoms  are  indigestion,  vomiting,  dragging  pain,  absence  of  normal 
splenic  dulness,  and  the  presence  in  the  abdomen  of  a  movable 
tumor  with  a  marked  notch.  The  chief  danger  is  twisting  of  the 
pedicle,  which  may  lead  to  gangrene  of  the  organ.  The  treatment 
is  the  application  of  a  pad  or  belt.  If  this  is  unsuccessful,  the  spleen 
may  be  removed,  or  sutured  to  the  abdominal  wall  {splenopexy) .  As 
sutures  are  apt  to  cut  out  and  cause  profuse  bleeding,  a  better  method 
is  to  slip  the  spleen  into  a  pocket  formed  by  separating  the  parietal 
peritoneum  from  the  abdominal  wall,  the  peritoneum  being  sutured 
to  the  abdominal  wall  at  the  bottom  of  the  pouch  (Rydygier's 
method).     Torsion  of  the  pedicle  and  gangrene  require  splenectomy. 

Abscess  may  be  caused  by  trauma,  extension  from  neighboring 
organs,  acute  infectious  diseases,  chronic  malaria,  and  pyemia. 
Chronic  suppuration  may  be  due  to  syphilis,  tuberculosis,  or  actino- 
mycosis. The  symptoms  are  pain,  tenderness,  and  enlargement  of  the 
spleen,  with  the  general  symptoms  of  sepsis.  The  treatment  is  the 
same  as  for  abscess  of  the  liver,  or  splenectomy  if  much  of  the  organ 
is  disorganized. 

Splenectomy  has  been  performed  for  (A)  local  and  (B)  general 
indications. 

A.  (i)  Splenoptosis  and  (2)  abscess  are  discussed  above,  (3) 
wr/'wr/V^under  contusions  of  the  abdomen."  (4)  Spontaneous  rupture 
may  occur  in  typhoidal  and  other  splenic  enlargements,  and  may 
demand  splenectomy  in  order  to  stop  the  bleeding.  (5)  Tumors  are 
rare,  the  most  frequent  being  sarcoma.  (6)  Aneurysm  of  the  splenic 
artery  also  is  rare.  (7)  Cysts  may  be  hemorrhagic,  serous,  lymphatic, 
dermoid  or  most  frequently  hydatid.  (8)  Idiopathic  splenomegaly, 
which  is  not  associated  with  marked  or  characteristic  blood  changes 
and  (9)  malarial  hypertrophy  are  indications  for  splenectomy  only 
when  the  local  discomfort  is  great;  removal  of  the  spleen  has  no  effect 
on  the  malaria.  (10)  Tuberculosis  of  the  spleen  is  almost  never 
primary,  hence  seldom  amenable  to  surgical  treatment. 

B.  For  the  discussion  of  the  medical  aspects  of  the  diseases 
mentioned  in  this  group  the  reader  is  referred  to  a  text-book  on 


798  MANUAL   OF    SURGERY 

medicine,  (i)  Splenic  anemia,  in  which  there  is  enlaigement  of  the 
spleen,  witii  diminution  in  the  number  of  white  and  red  blood  cells, 
and  a  reduction  in  the  percentage  of  hemoglobin,  responds  favorably 
to  splenectomy,  a  number  of  apparently  permanent  recoveries  being 
on  record.  (2)  In  BanWs  disease  (splenomegaly  with  cirrhosis  of  the 
liver) ,  which  many  regarded  as  a  later  stage  of  splenic  anemia,  splenec- 
tomy should  be  considered^  although  the  results  are  not  so  good  as  in 
splenic  anemia.  (3)  In  several  cases  of  anemia  infantum  {von 
Jaksch's  disease),  which  may  possibly  be  an  infantile  form  of  splenic 
anemia,  removal  of  the  spleen  has  been  followed  by  marked  immediate 
improvement.  (4)  Primary  splenomegaly  ( Gaucher 's  disease)  has 
been  treated  by  splenectomy  ten  times,  with  eight  recoveries  and 
two  deaths.  (5)  Pernicious  anemia  may  be  benefited  temporarily 
by  splenectomy.  The  mortality  is  about  20  per  cent.  (6)  Hemolytic 
jaundice  is  characterized  by  anemia,  jaundice,  and  splenomegaly. 
Two  forms  are  recognized,  the  congenital  {Chaufard-Minkowski) 
and  the  acquired  (Hayem-Widal).  In  both  increased  hemolysis 
is  indicated  by  an  excess  of  urobilin  in  the  urine  and  the  feces,  but  as 
the  jaundice  is  non-obstructive  there  is  bile  in  the  stools,  and  none  in 
the  urine  (acholuria).  The  erythrocytes  exhibit  lessened  resistance 
to  hypotonic  salt  solution,  and  in  the  acquired  form  auto-agglutina- 
tion. In  the  congenital  type  the  patients  are  often  more  icteric 
than  ill,  in  the  acquired  type  more  anemic  than  jaundiced.  Banti 
believes  he  has  discovered,  in  what  he  calls  splenomegalie  hemolytique, 
the  connecting  link  between  the  two  varieties  outlined  above,  but 
his  argument  is  not  convincing.  In  all  forms  of  hemolysis  due  to 
''hypersplenism,"  i.e.,  increased  destruction  of  the  red  cells  by  the 
spleen,  removal  of  the  organ  has  been  followed  by  excellent  results. 
Of  48  operations  collected  by  Elliott  and  Kanavel  only  two  were  fatal. 
The  most  important  sign,  so  far  as  the  indications  for  splenectomy 
are  concerned,  is  the  increased  quantity  of  urobilin  in  the  urine  and  the 
feces. 

The  principal  contraindications  to  splenectomy  are  leukemia; 
erythremia  (Vaquez's  disease),  in  which  there  is  enormous  increase 
in  the  number  of  erythrocytes,  hence  possibly  due  to  "  hyposplenism ;" 
splenomegaly  of  the  congestive  type,  resulting  from  cardiac  or  pul- 
monary disease;  marked  cachexia;  and  dense  universal  adhesions. 

The  operation,  in  many  cases  in  group  B,  should  be  preceded  by 
transfusion  of  blood.  A  long  incision  is  made  in  the  left  rectus  mus- 
cle. If  more  room  is  needed  the  incision  may  be  extended  upwards 
and  inwards,  along  the  costal  margin,  to  the  ensiform;  or  upwards 
and  outwards  along  the  eighth  intercostal  space,  the  cartilages  of  the 


ABDOMEN  799 

eighth,  ninth  and  tenth  ribs  being  excised,  after  reflection  of  the 
musculocutaneous  dap.  The  Hver  and  gall-bladder  should  always 
be  explored,  and  calculi,  if  found,  removed. 

The  phrenosplenic  ligament  is  tied  and  divided,  the  spleen 
delivered  through  the  wound,  and  each  vessel  of  the  pedicle 
severed  between  ligatures.  The  special  complications  are  injury  to 
the  stomach;  ligation  of  the  tail  of  the  pancreas  with  the  splenic 
pedicle,  an  accident  that  may  be  followed  by  fat  necrosis;  thrombosis 
of  the  splenic  vein,  which  may  extend  into  the  superior  or  the  in- 
ferior mesenteric  vein,  or  give  rise  to  embolism;  and  gastrointestinal 
hemorrhage,  possibly  the  result  of  extension  of  the  thrombosis. 
The  mortality  of  the  operation  for  all  conditions  is  about  25  per  cent. 

The  blood  changes  after  splenectomy  vary  with  the  condition  of  the 
spleen.  In  some  of  the  forms  of  anemia  mentioned  in  group  B  the 
blood  rapidly  regenerates.  After  removal  of  a  healthy  adult  spleen, 
e.g.,  for  injury,  there  is  a  reduction  in  the  number  of  red  cells  and  in 
the  percentage  of  hemoglobin,  an  increase  in  the  number  of  white  cells 
and  often  enlargement  of  the  lymph  glands  and  the  thymus,  with 
tenderness  of  the  bones  (the  red  cells  are  formed  by  bone  marrow) 
headache,  emaciation,  and  sometimes  rapid  pulse,  fever,  thirst, 
polyuria,  and  abdominal  uneasiness.  These  symptoms  may  last 
for  weeks  or  months  before  good  health  is  obtained.  The  changes 
may  be  absent,  or  at  least  not  so  decided,  because  the  compensatory 
organs  (hemolymph  glands,  thymus,  and  possibly  accessory  spleens) 
at  once  become  active,  e.g.,  in  children,  or  are  already  doing  the 
work  of  a  spleen  whose  functions  have  been  destroyed  by  disease. 
Extract  of  spleen,  thymus,  or  red  bone  marrow,  with  iron,  may  be  of 
service  in  lessening  the  evil  after  effects  of  splenectomy. 

ABDOMINAL  HERNIA,  OR  RUPTURE 

The  word  hernia  is  sometimes  employed  in  connection  with  the 
brain,  lung,  muscle,  or  other  parts,  but  when  used  without  qualifica- 
tion refers  to  an  external  abdominal  hernia,  which  is  a  protrusion  of 
a  portion  of  the  contents  of  the  abdomen  through  an  opening  in  the 
abdominal  wall,  the  protruded  parts  being  covered  at  least  by  skin, 
and  almost  always  by  peritoneum.  The  term  internal  hernia  is 
applied  to  a  visceral  protrusion  through  the  diaphragm,  through 
an  intraperitoneal  aperture,  e.g.,  the  foramen  of  Winslow.  When 
the  abdominal  contents  escape  through  a  wound,  or  when  an 
organ  is  extruded  through  a  normal  orifice,  e.g.,  the  uterus  thorough 
the  vulva,  the  condition  is  called  prolapse  and  not  hernia. 

The  causes  of  hernia  are  congenital  and  acquired.     Among  the 


8oO  MANUAL    OF    SURGERY 

congenital  causes  are  (i)  non-obliteration  of  a  normal  peritoneal 
diverticulum,  e.g.,  the  funicular  process,  which  precedes  the  testicle 
in  its  descent,  and  passes  along  the  spermatic  cord  or,  in  the  fernale, 
the  round  ligament;  (2)  abnormal  congenital  apertures,  ie.g.,  in  the 
mesentery,  diaphragm,  linea  alba,  or  linea  semilunaris;  (3)  unusually 
large  nomal  apertures,  e.g.,  the  umbilical,  inguinal,  and  femoral 
rings;  (4)  weakness  of  the  abdominal  muscles  (often  inherited);  (5) 
abnormal  length  of  the  mesentery  or  omentum;  and  (6)  imperfectly 
descended  testicles.  Among  the  acquired  causes  are  (i)  those  which 
weaken  the  abdominal  wall,  e.g.,  injuries  and  operations,  degeneration 
(from  senescence,  lack  of  exercise,  prolonged  illness),  and  over- 
stretching the  result  of  intraabdominal  swellings;(2)  those  which 
increase  the  intraabdominal  pressure,  e.g.,  ascites,  intraabdominal 
tumors,  pregnancy,  obesity,  tight  belts,  and  all  conditions  which 
necessitate  straining,  such  as  laborious  occupations,  phimosis,  en- 
larged prostate,  constipation,  and  diseases  of  the  air  passages  associ- 
ated with  persistent  cough;  and  (3)  those  which  drag  on  the 
peritoneum,  such  as  cicatrices  and  tumors,  particularly  the  subperi- 
toneal lipoma.  Hernia  is  most  frequent  in  the  first  year  of  life,  19.6 
cases  in  every  loco  individuals  according  to  Berger;  it  then  decreases 
in  frequency  until  the  minimum  is  reached  in  the  twentieth  to  the 
twenty-fourth  year,  and  gradually  increases,  owing  to  degeneration 
of  the  muscles,  as  age  advances.  Hernia  is  three  times  more  fre- 
quent in  males  than  in  females. 

In  structure  a  hernia  consists  of  (i)  an  orifice,  (2)  a  sac,  (3)  the 
coverings  of  the  sac,  and  (4)  the  contents,  i.  The  hernial  orifice, 
often  called  the  ring,  is  the  opening  in  the  parietes;  this  opening 
may  be  canalicular,  e.g.,  in  the  inguinal  region,  and  possess  an  inter- 
nal and  an  external  ring.  2.  The  sac  is  the  peritoneal  pouch 
enveloping  the  contents  of  the  hernia.  In  the  early  stages  of  an  ac- 
quired hernia  the  sac  is  thin  and  funnel-shaped;  later  it  becomes 
larger,  thicker,  and  more  globular.  It  consist*  of  a  neck  and  a  body, 
and  is  formed  by  stretching  and  sliding  of  the  peritoneum,  hence 
when  a  hernia  appears  suddenly,  excluding  actual  ruptures  of  the 
abdominal  muscles  {traumatic  hernia),  there  must  have  been  a  pre- 
formed (congenital)  sac.  As  the  result  of  irritation  or  inflammation, 
from  pressure  or  injury,  the  sac  may  become  adherent  to  the  contents, 
or  be  divided  into  two  (hour-glass)  or  more  saccules  or  diverticula. 
It  is  always  adherent  to  its  coverings,  hence  is  irreducible,  although  the 
contents  may  be  reducible.  Occasionally  the  sac  or  a  saccule  be- 
comes completely  shut  ofif  and  filled  with  fluid  (hydrocele  of  the  sac). 
As  the  sac  is  merely  a  peritoneal  diverticulum  it  may  participate  in 


ABDOMEN  8oi 

any  of  the  affections  of  the  peritoneal  cavity,  e.g.,  ascites,  carcinoma- 
tosis, tuberculosis,  acute  peritonitis.     A  peritoneal  sac  is  absent  in 
certain  sliding  hernias,  certain  hernias  following  abdominal  operations 
or  injuries,  and  in  most  internal  retroperitoneal  hernias.     A  slidiuf^ 
hernia  is  one  in  which  the  ascending  or  the  descending  colon  slip 
down   through   the   inguinal   canals.     As   these   structures   usually 
have  no  mesentery  the  posterior  portion  of  the  sac  is  generally 
absent.     3.  The  coverings  of  the  sac  vary  with  the  situation  of  the 
hernia    and    are  enumerated   with    the  individual    forms.     4.  The 
contents  may  be  any  abdominal  viscus,  but  only  those  organs  requir- 
ing special  mention  are  noted  below.     The  sac  usually  contains  small 
intestine  {enterocele) ,  omentum  (epiplocele),  or  both  (enteroepiplocele) . 
When  only  a  portion  of  the  circumference  of  the  intestine  lies  within 
the  sac  (partial  enterocele,  or  Richter's  hernia),  the  hernia  is  very  small, 
and  if  strangulation  occurs,  the  symptoms  of  obstruction  are  not 
complete.     Littre^s   hernia  is  a  hernia  of    Meckel's    diverticulum. 
The  cecum,  with  or  without  the  appendix,  has  been  found  in  even  a 
left  femoral  hernia  {cecocele).     As  it  usually  has  a  mesentery,  it 
generally  lies  within  the  hernial  sac;  but  when  the  mesentery  is 
absent,  the  cecum  may  be  partly  within  and  partly  without  the 
hernial  sac,  the  so-called  sliding  hernia  of  the  cecum.     The  bladder 
may  be  encountered  in  a  direct  inguinal  hernia  (cystocele).     As  a 
rule,   the  herniated  portion   of   the  bladder  is  partly  covered  with 
peritoneum  and  partly  extraperitoneal,  but  it  may  be  wholly  within 
or  without  the  sac.     The  condition  may  be  suspected  if  the  bladder 
is  irritable,  if  the  hernia  increases  in  size  when  the  bladder  is  filled 
and  lessens  in  size  when  it  is  emptied,  and  if  pressure  upon  the  hernia 
causes  a  desire  to  urinate.     The  diagnosis  may  be  confirmed  by 
injecting  water  into  the  bladder,  when  the  herniated  pouch  will 
distend;  by  cystoscopic  examination,  when  the  lateral  displacement 
of  the  vesical  wall  can  be  seen;  and  possibly  by  filling  the  bladder  with 
collargol   solution  and  taking  a   skiagram.     The   same  diagnostic 
remarks  apply  to  the  rare  hernia  of  a  vesical  diverticulum,  which  is 
devoid  of  muscular  fibres.     The  ovary  is  normally  a  pelvic  organ,  but 
may  be  arrested  in  its  descent  near  the  internal  inguinal  ring,  or  be 
raised  to  this  level  by  enlargement  of  the  uterus  (pregnancy,  tumors), 
hence  ovarian  hernia  is  most  frequent  in  infants,  and  in  women  who 
have  borne  children.     The  swelling  is  often  irreducible,  and  attempts 
at  reduction  cause  a  sickening  pain.     The  treatment  of  the  condi- 
tions mentioned  above  is  considered  later.     Loose  bodies,  sometimes 
as  large  as  marbles  and  probably  representing  detached  appendices 
epiploicae,  are  occasionally  found  in  the  sac  of  a  hernia. 

51 


8o2  MANUAL   OF    SURGERY 

The  signs  of  an  uncomplicated  enterocele  are:  (i)  a  soft  swelling, 
(2)  which  is  in  the  usual  situation  of  a  hernia,  (3)  is  inseparable  from 
the  abdominal  wall,  (4)  has  an  expansile  impulse  on  coughing,  (5) 
is  tympanitic  on  percussion,  (6)  disappears,  often  suddenly  and  with 
a  gurgle,  on  recumbency  or  pressure,  (7)  when  the  hernial  orifice 
may  be  felt,  and  (8)  which  reappears  when  the  patient  stands  or 
strains.  An  epiplocele  is  dull  on  percussion,  feels  more  doughy,  has 
a  less  marked  impulse,  and  reduction  is  more  difficult  and  unaccom- 
panied by  a  gurgle.  The  patient  may  complain  of  pain,  indigestion, 
and  constipation. 

The  treatment  may  be  palliative  (trusses)  or  radical  (operation), 
but  such  is  best  considered  with  the  special  forms  of  hernia. 

SPECUL  FORMS  OF  HERNIA 

Inguinal  hernia  constitutes  about  80  per  cent,  of  all  hernias;  it  is 
much  more  common  in  males,  because  of  the  larger  size  of  the  inguinal 
canal,  the  frequency  of  imperfect  closure  of  the  processus  vaginaHs, 
and  the  influence  of  strenuous  occupation;  and,  owing  to  the  later 
descent  of  the  right  testicle,  which  keeps  the  inguinal  canal 
patent  for  a  longer  period,  is  more  often  encountered  on  the  right 
side.  A  classification  of  the  principal  forms  of  inguinal  hernia  is 
given  in  the  subjoined  table. 

1.  Acquired     }  a.  Incomplete 
I  b.  Complete    (scrotal      or 

labial) 

2.  Congenital     a.  Vaginal 
I  b.  Funicular 
I  c.  Infantile 
I  d.  Encysted  infantile 

II.  Direct  (always  acquired)  f  i.  Intraparietal  |  Intrailiac 

III.  Interstitial  (usually  congenital)     2.  Interparietal  |  Antevesical 

[  3.  Extraparietal 

I. — The  indirect  or  oblique  inguinal  hernia,  enters  the  internal 
ring  in  the  external  inguinal  fossa,  external  to  the  deep  epigastric 
artery.  It  is  more  frequent  on  the  right  side,  for  the  reason  given 
above,  and  in  about  one-third  of  the  cases  a  similar  hernia  appears, 
sooner  or  later,  in  the  opposite  inguinal  region. 

I .  Acquired  indirect  inguinal  hernia  (Fig.  446) ,  in  which  the  sac 
is  gradually  formed  from  the  parietal  peritoneum,  may  (a)  distend  the 
inguinal  canal  only  {incomplete  inguinal  hernia  or  bubonocele),  or  it 


I.      Indirect  or  oblique 


ABDOMEN 


803 


may  (b)  i)ass  into  the  scrotum  [scrotal  hernia)  or,  in  the  female,  in- 
to the  labium  majus  {labial  hernia),  when  it  constitutes  a  complete 
inguinal  hernia  (Fig.  444).  The  coverings  of  a  complete  indirect 
inguinal  hernia  are  the  sac,  with  subperitoneal  fat;  infundibuliform 
fascia,  derived  from  the  transversalis  fascia;  cremasteric  fascia  and. 
muscle,  derived  from  the  internal  oblique;  intercolumnar  fascia,  de- 
rived from  the  external  oblique;  deep  and  superficial  fasciae;  and 
the  skin.  In  old  cases  the  internal  ring  may  be  directly  behind  the 
external  ring,  simulating  very  closely  a  direct  hernia.  The  sac 
always  lies  in  front  of  the  sper- 
matic cord. 

2.  Congenital  indirect  in- 
guinal hernia  owes  its  existence 
to  non-obliteration  of  the  funi- 
cular process  of  peritoneum.  It 
usually  appears  at  or  soon  after 
birth,  although  it  is  not,  as  the 
term  congenital  implies,  always 
present  at   this  time,  but  may  -j. 

occur  at  any  period  of  life  as  the 


Fig.   444. — Complete  oblique  hernia  on 
the  left,  bubonocele  on  the  right. 


Fig.   445. — Double  congenital  hernia. 


result  of  a  sudden  strain  forcing  apart  the  apposed  peritoneal 
layers,  indeed,  some  authors  go  so  far  as  to  attribute  practically 
all  hernias  to  a  persistent  antenatal  sac.  The  hernia  is  never 
gradual  in  onset  but  becomes  complete  at  once,  and  the  sac  is. 
invariably  -densely  adherent  to  the  cord.  Inguinal  hernia  in  the 
female  is  almost  always  congenital,  the  patent  tube  of  peritoneum 
(canal  of  Nuck)  following  the  round  hgament.  (a)  In  the  vaginal 
form  (^Figs.  440  and  447)  the  bowel  passes  directly  into  the  tunica 
vaginalis,  surrounding  and  concealing  the  testicle,  (b)  In  funicular 
hernia  (Fig.  448),  which  is  the  most  frequent  variety  of  all  inguinal 
hernias,  the  funicular  process  remains  patent  for  a  variable  distance, 


8o4 


MANUAL    OF    SURGERY 


but  is  always  shut  off  from  the  tunica  vaginaUs.  (c)  In  infantile 
hernia  (Fig.  449),  which  is  very  rare,  the  funicular  process  is  closed 
at  its  abdominal  end  only,  the  hernia  (in  a  special  sac)  passing 
downwards  behind  the  process  or  (d)  invaginating  it  {encysted 
infantile  hernia) ;  thus  there  are  three  layers  of  peritoneum  in  front 
of  the  hernia  (Fig.  450).     Any  inguinal  hernia,  but  more  particu- 


V  V  V  ^/  ^ 

Pig.  446.  Fig.  447.  Fig.  448.         Fig.  449.  Fig.  450. 

Fig.  446. — Acquired  inguinal  hernia.  Fig.  447. — Vaginal  form  of  congenitalinguinal 
hernia.  Fig.  448. — Hernia  into  funicular  process.  FiG.  449. — Infantile  hernia.  FiG. 
450. — Encysted  infantile  hernia. 

Diagram'of  herniae.     C.  Cord.     S.  Sac.     T.  Testicle.     V.  Tunica  vaginalis. 

larly  the  congenital  forms,  may  be  associated  with  a  hydrocele  of 
the  cord  or  testicle. 

11.^ — Direct  inguinal  hernia  (Fig.  451)  is  always  acquired,  gen- 
erally appears  late  in  life,  is  hemispherical  in  shape,  never  descends 
into  the  scrotum,  rarely  becomes  strangulated,  and  is  bilateral  in 
one-half  of  the  cases.  It  originates  in  the  internal  inguinal  fossa,  to 
the  inner  side  of  the  deep  epigastric  artery,  i.e.,  in  Hesselbach's 

triangle.  The  spermatic  cord  generally 
lies  to  the  outer  side  of  the  hernia, 
which  emerges  at  the  outer  side  of  the 
conjoined  tendon,  or  splits  or  pushes 
that  structure  before  it,  thus  entering 
the  inguinal  canal  and  appearing  at  the 
external  ring.  When  passing  to  the 
outer  side  of  the  conjoined  tendon  its 
coverings  are  the  same  as  those  of  in- 
direct inguinal  hernia,  except  that  the  transversahs  fascia  is  sub- 
stituted for  the  inf undibulif orm  fascia ;  the  conjoined  tendon  also  is 
added  to  the  coverings  when  the  hernia  pushes  that  structure 
before  it. 

III.— Interstitial  hernia,  instead  of  passing  regularly  through  the 
inguinal  canal,  insinuates  itself  between  the  layers  of  the  abdominal 
wall.  Over  one-half  of  the  cases  are  cryptrochids.  Three  forms  are 
described:     (i)  In   properitoneal   or   intraparietal   hernia,    the    sac 


Fig.   451. — Direct  inguinal  hernia. 


ABDOMEN  805 

lies  between  the  peritoneum  and  tlie  transversulis  fascia,  either 
extending  outwards  iiiilra iliac)  or  inwards  (antevesical).  If  there  is 
also  a  sac  in  the  scrotum  the  condition  is  called  hernia  en  bissac. 
(2)  In  intcrparielal  Jiernia  the  sac  may  be  between  the  transversalis 
muscle  and  fascia,  the  external  and  internal  oblique,  or  between  the 
external  oblique  and  the  transversalis  fascia,  the  other  muscles 
having  been  pushed  aside.  (3)  Superficial  inguinal  Jiernia  iexlra- 
parietal)  is  the  most  frequent  variety.  The  sac  passes  through  the 
inguinal  canal,  thence  outwards  and  upwards  along  Poupart's 
ligament,  between  the  external  oblique  and  the  skin,  or  more  rarely 
outwards  and  downwards  beneath  the  skin  of  the  thigh,  thus  pre- 
senting a  superficial  resemblance  to  femoral  hernia.  In  any  strang- 
ulated interstitial  hernia  in  which  the  sac  is  bilocular,  the  bowel  may 
be  pushed  from  the  superticial  into  the  deeper  sac,  and  the  sym.ptoms 
of  strangulation  persist  after  apparent  reduction;  this  is  the  explana- 
tion of  the  so-called  reduction  en  masse,  or  en  bloc,  it  being  very 
doubtful  whether  a  hernial  sac  is  ever  torn  from  its  attachments  and 
reduced  w'ith  the  contents. 

The  signs  of  an  inguinal  hernia  are  those  already  mentioned  in 
describing  the  general  features  of  hernia  (p.  802).  The  swelling 
increases  in  size  from  above  downwards  and  the  testicle  lies  below 
and  behind.  In  the  male  the  external  inguinal  ring  may  be  felt  by 
invaginating  the  skin  of  the  scrotum  with  the  index  finger;  if  it  enters, 
the  ring  is  abnormally  large. 

The  diagnosis  is  usually  easy,  but  may  be  difficult  or  impossible 
without  operation.  In  oblique  hernia  the  canal,  at  least  in  the 
beginning,  passes  upwards  and  outwards,  and  in  rare  instances  the 
deep  epigastric  artery  may  be  felt  to  the  inner  side.  Direct  hernia 
occurs  in  adults,  usually  stops  at  the  root  of  the  scrotum,  has  the 
deep  epigastric  artery  to  its  outer  side,  and  passes  directly  backwards 
through  the  abdominal  wall.  The  conditions  which  may  be  mistaken 
for  inguinal  hernia  are : 

I. — Reducible  swellings  which  give  (a)  an  expansile  or  (b)  a 
nonexpansile  (lifting)  impulse  on  coughing. 

(a)  Reducible  swellings  with  an  expansile  impulse:  (i)  In 
femoral  Jiernia  the  orifice  is  below  Poupart's  ligament  and  to  the 
outer  side  of  the  pubic  spine,  in  inguinal  hernia  above  Poupart's  liga- 
ment and  internal  to  the  pubic  spine  (Fig.  457).  In  the  former  the  in- 
guinal canal  remains  empty.  In  inguinal  hernia  reduction  is  effected 
by  pushing  upwards,  outwards  and  backwards  and  in  femoral 
hernia,  downwards  and  then  upwards  and  backwards.  (2)  Con- 
genital Jiydrocele  is   translucent,    and   slowly   reducible   without   a 


8o6  MANUAL    OF    SURGERY 

gurgle,  but  is  very  apt  to  be  associated  with  a  hernia.  (3)  Varicocele 
feels  like  a  "bag  of  worms,"  is  dull  on  percussion,  and  reappears 
from  below  upwards  after  compression,  even  when  the  finger  blocks 
the  inguinal  canal.  (4)  A  psoas  or  other  chronic  abscess  communi- 
cating with  the  abdominal  cavity  fluctuates,  is  dull  on  percussion; 
may  be  on  either  side  of  the  femoral  vessels,  and  may  be  associated 
with  other  signs  indicating  its  nature,  e.g.,  kyphosis,  mass  in  the 
iliac  region.  If  it  proceeds  from  bone  the  X-ray  may  show  the 
osseous  lesion. 

(b)  Reducible  swellings  with  a  nonexpansile  impulse  are  dull  on 
percussion,  (i)  Subperitoneal  lipoma  always  has  the  same  shape 
and  consistency;  it  may,  however,  be  the  pilot  of  a  hernial  sac. 
(2.)  In  undescended  testicle  the  scrotum  is  empty;  the  swelling  is 
elastic,  more  or  less  circumscribed,  and  gives  the  testicular  sensa- 
tion on  pressure.  There  is  usually,  however,  a  hernia  above  the 
testicle.  An  inflamed  or  twisted  undescended  testicle  may  give  symp- 
toms almost  identical  with  those  of  strangulated  hernia. 

II. — Irreducible  swellings,  all  of  which  are  dull  on  percussion, 
may  have  a  lifting,  but  never  an  expansile,  impulse:  (i)  Enlarged 
inguinal  glands  are  lobulated,  and  caused  by  irritation  in  the  area 
which  they  drain;  the  inguinal  canal  is  free.  (2)  Encysted  hydrocele 
of  the  cord  is  translucent,  elastic,  circumscribed,  and  cannot  be 
reduced  when  traction  is  made  on  the  cord.  (3)  In  hydrocele  of 
the  testis  the  swelling  develops  slowly,  beginning,  below  and  spreading 
upwards;  stands  out  from  the  abdomen,  from  which  it  may  be 
separated  by  the  fingers;  is  translucent  (unless  the  walls  are  very 
thick,  or  blood  or  spermatic  fluid  be  the  contents),  and  not  reducible 
(excepting  those  which  communicate  with  the  abdomen  or  with  a 
second  sac).  (4)  Hematocele  of  the  cord  follows  injury  and  is  associ- 
ated with  pain  and  ecchymosis.  (5)  Swelling  in  the  lower  scrotum, 
e.g.,  spermatocele,  hematocele,  orchitis,  tumors  of  the  testicle, 
etc.,  are  generally  readily  differentiated  from  hernia  by  the  freedom 
of  the  cord  above,  and  the  absence  of  a  swelling  in  the  inguinal 
canal. 

The  treatment  may  be  palliative  or  radical. 

Palliative  treatment  consists  in  the  application  of  a  truss  and  the 
removal  of  all  sources  of  straining.  A  year  or  two  of  this  treatment 
in  children  will  often  result  in  cure.  The  younger  the  child,  the 
greater  the  chances  of  cure.  A  truss  consists  of  a  pad  for  the  hernia, 
held  in  place  by  a  steel  spring,  which  passes  backward  on  the  same 
side,  midway  between  the  crest  of  the  ilium  and  the  top  of  the  tro- 
chanter, to  just  behind  the  anterior  superior  spine  of  the  opposite 


ABDOMEN  807 

side,  whence  it  is  continued  with  a  strap,  which  is  fastened  to  the 
pad.  A  second  strap  passing  beneath  the  thigh  may  be  necessary 
to  hold  the  truss  in  place.  The  pad  may  be  of  vulcanite,  rubber, 
etc.,  and  should  be  placed  over  the  internal  ring  in  oblique  hernia, 
over  the  external  ring  in  direct  hernia.  It  should  rest  on  the  soft 
tissues  only,  and  not  be  so  small  or  so  convex  as  to  project  into  and 
dilate  the  opening;  the  spring  should  be  strong  enough  to  retain 
the  hernia  under  all  strains,  but  without  injurious  pressure.  In 
adults  the  truss  is  ordinarily  worn  during  the  day,  being  put  on 
before  rising  and  removed  after  retiring.  In  young  children,  in 
whom  there  is  a  chance  of  cure,  the  truss  should  be  worn  also  at 
night,  as  a  single  escape  of  the  hernia,  even  after  months  of  treat- 
ment, will  cancel  all  the  good  which  has  been  done.  In  irreducible 
herniae  cup  or  bag  trusses  are  sometimes  employed. 

The  radical  treatment  of  inguinal  hernia  is  recommended  inall 
cases  after  the  age  of  three,  if  truss  treatment  has  failed,  and  up  to  the 
age  of  sixty,  providing  there  is  no  visceral  disease  to  contraindicate 
operation.  The  mortality  is  less  than  one  per  cent.,  recurrence 
less  than  two  per  cent. ;  80  per  cent,  of  the  latter  occur  within  the  first 
year.  These  statements  do  not  apply  to  enormous  hernias,  in 
which  the  danger  of  operation  is  by  no  means  small,  and  the  chances 
of  recurrence  very  great.  Direct  hernias  also  are  prone  to  recur, 
because  of  the  flabbiness  of  the  muscles,  the  large  size  of  the  orifice, 
the  absence  of  a  canal,  and  because  the  sac  is  often  formed  partly  by 
the  bladder  and  therefore  cannot  be  completely  removed.  While 
a  patient  with  a  reducible  hernia  and  a  comfortable  truss  may  be 
offered  operation,  one  with  a  hernia  which  is  irreducible,  which  a  truss 
does  not  retain,  which  occasionaly  becomes  incarcerated  or  inflamed, 
or  which  is  associated  with  an  undescended  testicle  or  a  reducible 
hydrocele,  should  be  urged  to  accept  radical  treatment.  Of  the 
many  operation?  that  have  been  advocated  for  this  purpose  only  two 
will  be  described. 

Bassini's  operation  is  the  one  most  frequently  employed.  An 
incision  is  made  parallel  with  and  one-half  inch  above  Poupart's  liga- 
ment, from  the  external  to  just  above  the  internal  ring.  The  super- 
ficial epigastric  and  the  superficial  external  pudic  vessels  are  secured, 
and  the  aponeurosis  of  the  external  oblique  divided  in  the  direction 
of  its  fibres,  from  the  external  ring  upwards  and  outwards,  the  flaps 
being  separated  from  the  subjacent  tissues.  The  sac  is  now  separated 
from  the  spermatic  cord  by  blunt  dissection,  opened  to  make  sure 
there  are  no  adherent  structures,  hgated,  as  high  as  possible,  with  cat- 
gut, and  severed  beyond  the  ligature,  the  stump  retracting  into  the 


8o8  MANUAL    OF    SURGERY 

abdominal  cavity.  The  spermatic  cord  is  separated  from  its  bed,  and 
held  aside  by  a  blunt  hook  or  loop  of  gauze  while  the  internal  oblique 
and  transversalis  muscles,  as  one  layer,  are  sutured  to  shelving  margin 
of  Poupart's  ligament  beneath  the  cord.  A  suture  should  be  placed 
also  above  the  cord  (Fig.  452) .  The  cord  is  now  placed  on  this  suture 
hne  and  the  incision  in  the  external  oblique  closed.  The  skin  is  sutured 
with  silkworm  gut,  after  ligating  all  bleeding  points.  Chromicized 
catgut  or  kangaroo  tendon  is  used  for  the  buried  sutures.  In 
children  it  is  well  to  seal  the  wound  with  collodion  before  applying 
the  spica  of  the  groin.  The  scrotum  is  supported  for  the  first  week. 
The  patient  remains  in  bed  for  two  weeks,  and  should  undertake 
no  straining  efforts  for  six  months.  A  truss  is  not  needed  after 
operation. 

The  chief  objection  to  the  Bassini  operation  is  that  edema  of  the 

cord,  hydrocele,  and  orchitis  occasion- 

//VT.  OBLIQUE ATRANSVEHSaLIS  ,         ].  •  •  r 

FXT.  OBLIQUE  pouPARJs  iiG.    ally  follow,  owmg  to  the  haudhug  of 

the  cord  and  its  compression  between 
the  layers  of  the  abdominal  wall. 

The  author's  method  combines 
some  of  the  features  of  the  foregoing 
and  the  Ferguson  operations,  with 
imbrication  of  the  layers  of  the  ab- 
dominal wall  in  a  manner  which, 
although  devised  independently,  is 
much  like  that  previously  suggested 
by  Andrews.     After  incising  the  skin 

Fio.   452. — Bassini's  operation.  i     i  i-  i       m-    • 

and  the  external  oblique  the  ilioingu- 
inal nerve  is  retracted ,  the  cremasteric  muscle  and  tascia  and  the  in  un- 
dibuliform  fascia  are  raised  from  the  cord  and  divided  longitudinally, 
and  the  sac,  which  lies  immediately  beneath,  is  isolated  by  gentle 
gauze  dissection,  so  as  to  injure  the  cord  as  little  as  possible,  and 
opened.  Adherent  omentum  is  divided  between  ligatures;  adherent 
intestine  gently  separated,  unless  the  adhesions  are  dense,  when  it  is 
better  to  leave  a  portion  of  the  sac,  thus  preventing  the  raw  surface 
which  would  otherwise  result.  A  finger  is  passed  into  the  abdomen, 
and  the  internal  inguinal  ring  of  the  opposite  side  and  both  internal 
femoral  rings  palpated.  The  vicinity  of  the  internal  ring  on  the  side 
of  operation  is  now  explored  for  diverticula,  properitoneal  hernia, 
and  laxity  of  the  peritoneum  to  the  inner  side  of  the  deep  epigastric 
vessels  (potential  direct  hernia) .  If  another  hernia  is  found  it  may 
be  dealt  with  through  the  same  incision,  if  on  the  same  side;  or, 
later,  through  a  separate  incision,  if  on  the  opposite  side.     The  neck 


ABDOMEN 


809 


of  the  sac,  which  is  recognized  by  following  the  peritoneum  until  it 
expands  l)encath  the  j^arictcs,  where  it  is  covered  with  properitoneal 
fat,  and  by  identifying  and  pushing  aside  the  deep  epigastric  vessels, 
is  palpated  for  thickening.  If  the  thickening  is  soft  one  should  suspect 
hernia  of  the  bladder  or  sliding  hernia  of  the  colon,  conditions  in 


/M  08  LI  00 E  S  TM  us  VERSA  us 


EXT.  0BIIQU£^ 
POOPARTS  Og  .  -" 


SKi/i   ; 

CO/iO 
EXT.OBLIQUE 


Fig.  453. — The  transversalis,  internal 
oblique,  and  external  oblique  muscles,  as 
one  layer,  are  sutured  to  Poupart's  ligament. 


Pig.  454. — Alternate  deep  and  super- 
ficial sutures  inserted. 


EXT.  OBLIQUE 


K'O/iD 


which  the  affected  viscus  may  readily  be  injured  in  ligating  the  sac. 
The  parietal  peritoneum  above  the  neck  of  the  sac  is  now  transfixed  and 
ligated  with  catgut,  and  the  stump  transplanted  upwards  and 
inwards  beneath  the  transversalis  fascia,  by  carrying  the  ends  of  the 
ligature  through  the  fascia  and  muscles  and  tying  them.  This 
transplantation  is  particularly  in- 
dicated in  sliding  hernias  and  in 
cases  in  which  the  peritoneum  to 
the  inner  side  of  the  epigastric  vessels 
is  lax.  The  internal  ring  is  made 
snug  by  passing  one  or  two  sutures 
through  the  transversalis  fascia  above 
the  cord.  The  canal  is  closed  over 
the  cord,  by  suturing  all  the  struc- 
tures on  the  inner  side  (transversalis,  Fi<^-  455- 
internal  oblique,  external  oblique)  to 
Poupart's  ligament,  beginning  below  and  extending  up  as  far  as  the 
attachment  of  the  muscles  to  Poupart's  ligament  (Fig.  453).  The 
fascia  of  the  external  oblique  thus  acts  as  a  splint  for  the  muscular 
fibres,  which,  if  sutured  alone,  tend  to  separate.  The  needle  should 
be  passed,  from  without  inwards,  through  the  structures  on  the 
inner  side  of  the  canal,  then,  from  within  outwards,  through  Poupart's 
ligament  while  a  finger   protects  the  femoral  vessels.     In  order  to 


Imbrication  of  the  external 
oblique. 


8lO  MANUAL    OF    SURGERY 

secure  accurate  coaptation  alternate  deep  and  superficial  sutures  are 
employed,  this  also  prevents  the  tearing  apart  of  the  muscular  and 
fascial  bundles  that  sometimes  follows  when  all  the  sutures  are  in- 
serted in  the  same  plane  (Fig.  454).  The  lower  is  now  sutured  up 
over  the  upper  flap  of  the  external  oblique  (Fig.  455)  and  the  skin 
closed. 

Variations  in  the  operations  detailed  above,  which  operations 
apply  particularly  to  the  ordinary  acquired  form  of  oblique  inguinal 
hernia  in  the  male,  may  be  desirable  or  necessary  under  certain 
circumstances. 

In  the  female  the  round  ligament  may  be  treated  like  the  sperma- 
tic cord,  but  as  there  is  some  difficulty  in  dissecting  the  sac  from  the 
ligament,  and  as  removal  of  the  ligament  in  the  inguinal  canal  permits 
complete  obliteration  of  the  canal,  it  is  better  to  tie  the  round  liga- 
ment and  the  sac  together,  transplanting  the  stump  to  the  inner 
aspect  of  the  abdominal  wall  as  previously  described. 

In  congenital  hernia  in  the  male  (vaginal  form)  the  entire  sac,  ex- 
cept the  testicular  layer  of  the  tunica  vaginalis,  may  be  excised,  a 
difficult  and  tedious  proceeding;  the  upper  portion  of  the  sac  may 
be  removed,  and  the  opening  in  the  lower  portion  sutured  to  form 
the  tunica  vaginahs;  or,  what  is  more  simple,  the  neck  of  the  sac 
may  be  ligated,  divided  below  the  Hgature,  and  the  sac  turned  inside 
out,  as  in  the  eversion  operation  for  hydrocele. 

Direct  hernia  is  exposed  in  the  same  manner  as  the  obhque  form, 
except  that  instead  of  incising  the  infundibuHform, fascia  over  the 
cord,  the  transversalis  fascia  must  be  divided  in  Hesselbach's  triangle, 
the  fascia  subsequently  being  overlapped  by  means  of  sutures.  The 
internal  ring  is  not  concerned  in  direct  hernia,  but  should  be  treated 
as  in  obhque  hernia  if  it  seems  too  large.  The  inguinal  canal  is 
closed  as  already  indicated  for  indirect  hernia,  most  operators  pre- 
ferring transplantation  of  the  cord,  as  in  the  Bassini  operation,  in 
order  to  fortify  Hesselbach's  triangle  with  a  layer  of  muscle. 

Transplantation  of  periosteum  or  fascia  lata  has  been  employed 
in  cases  in  which  the  hernial  orifice  is  large  and  the  muscular  struc- 
tures atrophied.  A  pedunculated  flap  may  be  turned  outwards 
and  downwards  from  the  sheath  of  the  rectus  muscle  and  sutured  to 
Poupart's  ligament,  or  the  sheath  may  be  incised  and  the  muscular 
fibers  drawn  down  to  the  ligament,  but  as  both  these  procedures 
weaken  the  rectus  they  are  not  recommended. 

In  interstitial  hernia,  in  addition  to  tracing  carefully  the  relations 
of  the  sac,  it  will  usually  be  necessary  to  deal  with  an  undescended 
testicle  (q.v.).     In  the  only  case  of  preperitoneal  inguinal  hernia  in 


ABDOMEN  8ll 

which  we  have  operated,  the  incision  was  made  in  the  median  Hne, 
owing  to  failure  to  recognize  the  cause  of  the  obstructive  symptoms, 
and  the  sac  obHterated  from  within  the  abdomen. 

In  sliding  hernia  of  the  colon  there  are  three  dangers  to  be  re- 
membered. The  extraperitoneal  portion  of  the  bowel  may  be  incised 
for  the  sac.  The  peritoneal  reflections  from  the  bowel  may  be  mis- 
taken for  adhesions,  sej^aration  of  which  on  the  mesial  side  may  result 
in  damage  to  the  nutrient  vessels  and  gangrene  of  the  intestine. 
When  a  large  hernia  of  the  ordinary  variety  grows  chiefly  at  the 
expense  of  the  parietal  peritoneum  on  the  outer  side  of  the  internal 
inguinal  ring,  a  small  section  of  the  colon,  partly  covered  with  peri- 
toneum, may  appear  in  the  neck  of  the  sac,  and,  being  regarded  as 
merely  a  thickening  of  the  tissues  at  this  point,  be  ligated  with  the 
sac.  If  one  suspects  a  sliding  hernia  of  the  colon  the  sac  should 
never  be  opened  to  the  outer  side  or  posteriorly,  and  never  without 
making  certain  that  only  the  peritoneum  is  being  divided ;  adhesions 
and  thickenings  must  always  be  carefully  investigated.  After 
incising  the  sac  well  to  the  inner  side,  the  flap  of  peritoneum  thus 
formed  can  be  wrapped  around  the  bowel  and  fastened  with  a  few 
stitches,  so  as  to  form  a  mesocolon.  The  bowel  may  then  be  reduced, 
and  the  remaining  opening  in  the  peritoneum  closed  with  sutures. 
In  order  to  prevent  recurrence  some  surgeons  advise  suturing  the 
herniated  bowel  to  the  anterior  abdominal  wall  (colopexy)  through  a 
separate  incision.  Our  own  practice  is  to  excise  the  sac,  close  the  peri- 
toneal opening  with  a  purse-string  suture,  and  transplant  the  puckered 
closure  in  the  manner  already  described  for  transplantation  of  the 
stump  of  the  sac  in  ordinary  oblique  hernia,  except  that  the  displace- 
ment is  upwards  and  outwards,  instead  of  upwards  and  inwards;  the 
herniated  colon  is  thus  carried  nearer  to  its  normal  situation,  and 
fixed  to  the  abdominal  wall. 

Hernia  of  the  bladder,  as  pointed  out  in  the  general  remarks  on 
the  structure  of  hernia,  may  be  diagnosticated  before  operation. 
In  most  instances,  however,  the  condition  is  not  recognized  until 
the  bladder  is  exposed,  and,  in  some  instances,  incised,  an  extraperi- 
toneal vesical  pouch  being  mistaken  for  the  sac.  In  the  event  of 
such  an  accident  the  wound  should  be  sutured  like  a  wound  in  the 
intestine,  and  a  retention  catheter  passed  into  the  bladder  through 
the  urethra.  Ligation  of  a  portion  of  the  bladder  with  the  sac  like- 
wise has  occurred,  urine  escaping,  after  the  ligated  piece  of  bladder 
has  sloughed,  into  the  peritoneum  or  the  extraperitoneal  cellular 
tissue.  The  bladder  lies  to  the  inner  side  of  and  behind  the  other 
contents  of  the  rupture,  and  is  usually  covered  with  a  large  quantity 


8l2 


MANUAL    OF    SURGERY 


of  fat.  As  a  rule,  it  can  be  easily  recognized  by  palpation,  after 
opening  the  sac  well  to  the  outer  side.  The  appearance  of  the  muscu- 
lar fibres  is  distinctive,  but  they  may  be  absent  in  a  diverticulum  of 
the  bladder.  If  there  is  tloubt,  the  bladder  may  be  distended  or  a 
sound  passed  into  it.  A  vesical  diverticulum  should  be  excised,  but 
a  protrusion  consisting  of  all  the  coats  of  the  bladder  should  be 
reduced,  and,  after  transplanting  the  neck  of  the  sac  upwards  and 
inwards,  the  inguinal  canal  closed  in  the  usual  manner. 

A  herniated  ovary,  Fallopian  tube,  or  uterus  should  be  reduced  if 
healthy,  removed  if  diseased. 

Femoral  hernia  (Fig.  456)  constitutes  10  per  cent,  of  all  hernias, 
and  is  more  frequent  in  females  owing  to  the  larger  size  of  the  crural 
canal,  consequent  upon  the  wider  pelvis,  but  even  in  females  it  is 
less  common  than  the  inguinal  variety.  The  hernia  passes  along 
the  femoral  canal  and  protrudes  through  the  saphenous  opening. 

The  internal  ring  is  formed  by 
Poupart's  ligament  in  front,  the 
pectineal  line  and  fascia  behind, 
Gimbernat's  ligament  on  the  in- 
side, and  the  inner  septum  of  the 
femoral  sheath  on  the  outside. 
The  external  ring  is  formed  by  the 
saphenous  opening.  Occasionally 
the  obturator  artery  arises  from 
the  deep  epigastric  and  passes  along 
the  edge  of  Gimbernat's  ligament. 
The  coverings  of  a  femoral  hernia  are  peritoneum,  septum  crurale, 
anterior  layer  of  the  femoral  sheath,  cribriform  fascia,  deep  and 
superficial  fasciae,  and  the  skin.  After  the  hernia  has  passed  through 
the  saphenous  opening,  it  is  bent  at  an  angle,  and  usually  passes 
upwards  and  outwards,  because  of  the  attachment  of  the  deep  layer 
of  the  superficial  fascia. 

The  signs  are  those  of  other  forms  of  hernia  (p.  802) .  The  swell- 
ing is  seldom  large,  and,  owing  to  the  amount  of  fat  on  the  sac,  is 
usually  more  or  less  lobular,  and  may  still  be  perceptible  even  after 
reduction  of  the  contents.  The  neck  lies  to  the  inside  of  the  femoral 
vessels,  to  the  outer  side  of  the  pubic  spine,  and  below  Poupart's 
ligament. 

The  diagnosis  is  facilitated  by  determining  the  exact  situation  of 
the  swelling.  (Fig.  457).  The  distinguishing  features  of  inguinal 
hernia,  enlarged  glands,  lipoma,  and  psoas  abscess  are  given  under  the 
Diagnosis  of  Inguinal  Hernia.     An  iliopsoas  bursa  limits  extension 


Fig.   456. — Femoral  hernia. 


ABDOMEN 


813 


of  the  hip  appears  outside  the  femoral  vessels  and  is  dull  on  percus- 
sion. Wirix  of  the  saphenous  vein  at  the  saphenous  opening  has  all 
the  signs  of  an  enteroccle,  except  that  it  is  dull  on  percussion.  How- 
ever, the  walls  of  a  sacular  venous  dilatation  are  thin  (not  thick  and 
fatty)  and  the  contents  fluid.  The  swelling  may  be  reduced,  but 
with  a  thrill  instead  of  a  gurgle,  and  it  reappears  from  below  upwards, 
even  when  the  linger  blocks  the  femoral  canal.  The  veins  below  are 
often  dilated,  and  if  one  taps  on  them  a  wave  can  be  felt  in  the  tumor, 
and  vice  versa.  Obturator  hernia  lies  deep  under  the  adductor  mus- 
cles and  is  very  rare  (vide  infra). 

POUPARJS  I/O  4NT  CRURAL   NERU 

:   FEMORM  VESSELS. 

^  ..,1<;^^,  /     ;    S/lFNfA'OUS  VE/V. 

^%x%S^n/"    ;     \£XT.//VG.R//VG. 

^  ^      J^ci  ^'^     '•.       CORD. 


Fig.  457. — Situation  of  swellings  in  the  groin,  (i)  Inguinal  hernia.  (2)  Femoral 
hernia;  saphenous  opening.  (3)  Obturator  hernia.  (4)  Iliopsoas  bursa.  (5,  5,  5) 
Inguinal  lymph  glands.     (2  and  6)  Femoral  lymph  glands. 

The  treatment  may  be  palliative,  a  truss  somewhat  similar  to 
that  used  for  inguinal  hernia  being  employed,  except  that  the  pad 
rests  over  the  femoral  canal  at  the  level  of  Gimbernat's  ligament. 

The  operative  treatment  is  simple,  safe,  and  satisfactory.  Bas- 
sini's  operation  is  as  follows:  An  incision,  parallel  with  and  below 
Poupart's  ligament,  is  made  over  the  sac,  which  is  isolated,  opened, 
and  ligated  as  in  inguinal  hernia.  Poupart's  ligament  is  then  sutured 
to  the  pectineal  fascia,  to  close  the  internal  ring,  and  the  plica  falci- 
formis  of  the  fascia  lata  is  sutured  to  the  pectineal  fascia,  thus  closing 
the  canal  (Fig.  458).  Care  should  be  taken  not  to  injure  or  compress 
the  femoral  vein. 

In  cases  in  which  there  is  a  coexisting  inguinal  and  femoral  hernia, 
the  latter  can  be  dealt  with  through  the  inguinal  canal.     Indeed 


8l4  MANUAL    OF    SURGERY 

some  operators  prefer  the  inguinal  route  for  all  cases  of  femoral  hernia, 
pointing  out  that,  when  approached  from  above,  the  sac  is  more 
certain  to  be  removed  in  its  entirety  and  the  internal  femoral  ring 
more  efifectively  sutured.  The  inguinal  canal  is  opened  as  for 
inguinal  hernia;  the  round  ligament  or  spermatic  cord  retracted 
upwards;  the  transversalis  fascia  in  Hesselbach's  triangle  incised 
parallel  with  and  close  to  Poupart's  ligament,  care  being  taken  not 
to  injure  the  deep  epigastric  vessels;  the  peritoneum  opened;  the  sac 
drawn  from  its  canal  by  steady  traction,  aided,  if  need  be,  by  snip- 
ping the  border  of  Gimbernat's  ligament,  or,  in  cases  in  which  the  sac 
is  closely  adherent  beneath  the  skin,  by  undermining  the  lower  edge 
of  the  cutaneous  incision;  the  sac  excised  after  ligation  of  its  neck; 
the  internal  femoral  ring  obliterated  by  passing  sutures  through 
Cooper's  and  Poupart's  hgaments;  the  transversalis  fascia  sutured; 
and  the  inguinal  sac  closed  as  in  the  operation  for  inguinal  hernia. 


POUPARTS   LIG 


FEMORAL  VESSELS 


PLICA  FALCIFORMIS 
SAPHENOUS    VEIN 


Fig.   458. — Bassini's  operation  for  femoral  hernia. 

Umbilical  hernia  represents  5  per  cent,  of  all  hernias.  There  are 
three  forms: 

1.  Congenital  umbilical  hernia,  or  exomphalos,  is  the  result  of 
imperfect  closure  of  the  abdominal  walls,  the  contents  varying  from 
a  small  loop  of  bowel  to  a  large  part  of  the  viscera  {ectopia  viscerum). 
The  hernia  is  covered  by  a  transparent  membrane  composed  of 
peritoneum  and  tissues  of  the  umbilical  cord.  The  condition  is  rare 
and  if  overlooked  the  bowel  may  be  tied  with  the  cord.  The  treat- 
ment of  a  small  hernia  is  an  aseptic  dressing,  with  pressure.  In  larger 
protusions  the  contents  should  be  reduced,  the  sac  removed,  and  the 
opening  closed  with  sutures,  as  cases  in  which  operation  is  with- 
held are  quickly  fatal  from  sloughing  of  the  sac. 

2.  Infantile  umbilical  hernia  is  due  to  stretching  of  the  umbilical 
cicatrix,  consequently  does  not  appear  as  a  rule  until  the  child  is 
several  weeks  or  months  old.  The  hernia  is  usually  of  small  size 
and  tends  towards  spontaneous  recovery.  Operation  is  therefore 
seldom  required,  unless  the  rupture  persists  after  puberty.  All 
sources  of  straining,  e.g.,   constipation,  phimosis,  etc.,  should  be 


ABDOMEN  815 

removed,  and  reduction  maintained  by  a  flat  pad,  larger  than  the 
ring  (a  covered  penny  is  often  employed),  held  in  place  by  a  broad 
strap  of  adhesive  plaster. 

3.  Umbilical  hernia  of  adults  is  caused  by  stretching  or  rupture 
of  the  tissues  in  the  immediate  vicinity  of  the  umbiUcus,  as  the 
result  of  increased  intraabdominal  pressure,  hence  is  most  frequent 
in  obese  women  who  have  borne  many  children.  In  most  cases  the 
protrusion  begins  at  the  point  where  the  umbilical  vein  passed  into 
the  abdomen,  i.e.,  at  the  upper  margin  of  the  naval,  which  is  dis- 
placed downwards  or  to  one  side.  The  hernia  often  attains  a  large 
size,  and  as  it  is  exposed  to  various  forms  of  irritation,  the  contents 
are  prone  to  become  adherent  to  one  another  and  to  the  sac.  Not 
infrequently,  therefore,  the  sac  is  divided  into  several  parts,  and  the 
hernia  is  often  irreducible,  thus  predisposing  to  strangulation.  The 
coverings  are  peritoneum,  transversalis  fascia,  and  skin,  or,  in  some 
instances,  only  peritoneum  and  very  thin  skin.     Ulceration  of  the 


■SKIN 

-SUTURED 
PERITONEUM 

-APONEUROSIS 


Fig.  459. — Mayo's  operation. 

coverings  may  occur,  but  perforation  or  actual  rupture  is  the 
exception. 

The  treatment  should  be  palliative,  if,  in  the  absence  of  serious 
complications,  the  patient  is  advanced  in  years  and  extremely  fat. 
A  pad  truss  should  be  worn,  unless  the  rupture  is  irreducible,  when 
some  form  of  cup  or  bag  truss  may  be  needed. 

The  Mayo  operation  is  the  most  satisfactory  in  cases  in  which 
radical  treatment  is  indicated.  The  hernia  is  surrounded  by  trans- 
verse elliptical  incisions  and  the  aponeurotic  structures  about  the 
ring  exposed.  The  sac  is  opened,  and  divided  at  its  neck,  adherent 
intestines  separated  and  reduced;  adherent  omentum  ligated,  and 
removed  with  the  sac  and  skin.  The  peritoneum  is  separated  from 
the  edges  of  the  ring  and  sutured  transversely.  Mattress  sutures 
of  chromicized  catgut  are  introduced  an  inch  or  more  above  the 
edge  of  the  upper  flap,  catching  the  margin  of  the  lower  flap  en  route, 
thus  sliding  it  into  the  space  between  the  peritoneum  and  upper 
flap  (Fig.  459).     The  lower  edge  of  the  upper  flap  is  sutured  to  the 


8l6  MANUAL    OF    SURGERY 

aponeurosis  below.  Konig  suggests  fortifying  the  line  of  suture, 
in  operations  for  umbilical  and  other  forms  of  hernia,  by  covering  it 
with  a  free  transplant  of  fascia  or  periosteum,  which  is  fixed  in  place 
with  catgut  stitches.  Very  large  hernial  orifices  have  been  closed 
by  the  implantation  of  a  perforated  celluloid  plate  or  a  network  of 
silver  wire 

Ventral  hernia  is  a  hernia  in  any  portion  of  the  anterior  abdomi- 
nal wall,  excepting  those  mentioned  above.  It  may  be  median  or 
lateral.  There  are  two  principal  varieties  of  median  hernia. 
I.  Hernia  of  the  linea  alba  forms  i  per  cent,  of  all  cases  of  hernia. 
It  is  most  frequent  about  midway  between  the  umbiHcus  and  the 
ensiform  {epigastric  hernia),  at  the  point  where  the  middle  linea 
transversa  of  the  rectus  joins  the  median  line,  because  at  this  point 
the  greatest  strain  occurs  when  the  recti  are  brought  into  action;  it 
is  usually  preceded  by  a  subperitoneal  lipoma,  which  insinuates 
itself  between  the  meshes  of  the  Hnea  alba  and  draws  a  sac  of  peri- 
toneum after  it.  Sometimes  a  lipoma,  with  or  without  a  hernial 
sac,  appears  just  above  the  umbiHcus,  at  the  juncture  of  the  lowest 
linea  transversa  with  the  median  line,  and  occasionally  there  are 
several  lipomata  between  the  ensiform  and  the  umbilicus.  Con- 
genital apertures  in  the  linea  alba  are  very  rare.  Epigastric  hernia 
is  most  common  in  healthy,  hard  working  men,  and  is  frequently 
insignificant  in  size,  hence  overlooked.  It  may  cause  epigastric 
pain,  vomiting,  and  other  gastric  symptoms.  Truss  treatment  is 
inapphcable  as  the  hernia  is  seldom  reducible.  The  lipoma  should 
be  excised  with  the  sac,  and  the  opening  in  the  abdominal  wall 
closed  with  sutures.  The  stomach  and  adjacent  organs  should 
always  be  explored  at  the  same  time,  to  make  sure  that  the  symp- 
toms are  not  due  to  some  graver  disease.  2.  Diastasis  of  the  recti 
muscles  is  most  commonly  observed  in  multipara;  it  causes  a  stretch- 
ing of  the  linea  alba,  which  encourages  a  prolapse  of  all  the  abdominal 
viscera.  The  diagnosis  is  readily  made  by  having  the  patient, 
when  lying  down,  fold  the  arms  and  raise  the  head  and  shoulders, 
the  whole  linea  alba  bulging  forwards  in  a  long  mound-hke  eminence, 
reaching  from  the  ensiform  to  the  pubes  The  treatment  is  that  of 
Glenard's  disease.  In  some  cases  marked  benefit  has  been  obtained 
by  suturing  the  recti  together,  or,  better,  by  overlapping  them,  with 
the  redundant  linea  alba.  Lateral  ventral  hernia  is  most  frequent 
in  the  senilunar  line  at  a  point  where  it  is  crossed  by  the  omphalo- 
spinous  line,  owing  to  the  fact  that  a  branch  of  the  epigastric  artery 
pierces  the  wall  in  this  situation.  It  is  the  result  of  increased  intra- 
abdominal pressure.     Postoperative  or  postincisional  herniae  may, 


ABDOMEN  817 

of  course,  occur  in  any  portion  of  the  abdomen,  and  are  particularly 
prone  to  develop  if  the  wound  suppurates  or  if  drainage  has  been 
em])loyed.  As  the  contents  of  the  hernia  are  often  adherent  to  the 
coverings,  and  a  peritoneal  sac  may  be  absent,  instead  of  incising 
directly  over  the  protrusion,  it  is  usually  safer  to  enter  the  abdomen 
above  or  below  the  old  wound,  and  then,  after  exploration,  excise 
the  cutaneous  scar,  separate  adhesions,  reduce  the  extruded  parts, 
and  close  the  wound  by  imbrication  of  the  individual  layers  of  the 
abdominal  wall. 

Among  the  rarer  forms  of  hernia  are  the  following:  Obturator 
hernia  passes  through  the  obturator  foramen  with  the  obturator 
vessels,  appearing  deep  in  the  thigh  on  the  inner  side  of  the  femoral 
vessels  (Fig.  457).  Eckstein  (191 2)  collected  194  cases.  The 
condition  is  more  common  in  women  (8  to  i)  because  of  the  larger 
size  of  the  foramen.  There  may  be  pain  in  the  hip  and  along  the 
inside  of  the  thigh  and  knee,  due  to  pressure  on  the  obturator  nerve. 
Bimanual  examination  may  reveal  a  cord-like  mass  extending  to 
the  foramen.  The  diagnosis  is  seldom  made;  even  when  the  hernia 
is  strangulated,  the  condition  is  rarely  suspected  until  after  the 
abdomen  has  been  opened  for  intestinal  obstruction.  The  sac  may 
be  exposed  by  an  incision  in  the  upper  and  inner  angle  of  Scarpa's 
triangle,  and  the  constriction  relieved  by  cutting  inwards,  since 
the  obturator  artery  usually  lies  below  and  to  the  outer  side.  The 
opening  may  be  closed  with  a  flap  of  muscle  or  periosteum.  The 
mortality  is  70  per  cent. 

Lumbar  hernia  occurs  in  Petit 's  triangle,  and  is  treated  as  a 
ventral  hernia. 

Sciatic  hernia  emerges  from  the  pelvis  through  one  of  the  sciatic 
foramina,  and  appears  in  the  gluteal  region. 

Perineal  hernias  aret  hose  passing  through  the  pelvic  diaphragm 
and  appearing  in  the  perineum,  towards  the  rectum  (rectal  hernia), 
vagina  {vaginal  hernia),  or  in  the  lower  part  of  the  labium  {pudendal 
hernia).  Inguinal  perineal  hernia  is  one  which  follows  an  aberrant 
testicle  into  the  perineum. 

Internal  hernia  occurs  in  two  forms,  (i)  the  diaphragmatic,  and 
(2)  the  retroperitoneal. 

I.  Diaphragmatic  hernia  is  more  frequent  on  the  left  side, 
because  the  diaphragm  is  weaker  at  this  point,  and  because  the 
liver  is  on  the  right  side.  Although  any  of  the  abdominal  viscera 
may  pass  into  the  thorax,  the  stomach  and  transverse  colon  are  the 
organs  usually  herniated.  The  hernia  may  be  (a)  congenital  or 
(b)  acquired. 

52 


8l8  MANUAL    OF    SURGERY 

(a)  The  congenital  form  is  the  more  frequent.  When,  as  is 
usually  the  case,  it  arises  before  the  separation  of  the  thorax  from 
the  abdomen,  it  passes  through  a  developemental  defect  in  the 
diaphragm,  and  has  no  sac  (false  diaphragmatic  hernia).  When 
it  protrudes  through  an  unusually  large  normal  aperture,  e.g.,  the 
esophageal  opening,  it  may  have  a  sac  {true  diaphragmatic  hernia). 

(b)  The  acquired  form  may  follow  a  crush  of  the  thorax  or  a 
severe  twist  of  the  body,  resulting  in  rupture  of  the  diaphragm,  or 
it  may  follow  a  stab  or  gunshot  wound,  hence,  has  no  sac  (false 
diaphragmatic  hernia). 

The  symptoms  are  abdominal  pain,  dyspnea,  vomiting,  some- 
times hematemesis,  and,  in  the  event  of  strangulation,  those  of 
acute  intestinal  obstruction.  Volvulus  of  the  stomach  (q.v.)  is  a 
possibility.  It  must  be  noted  that,  in  many  instances,  the  con- 
genital form  causes  no  trouble.  In  traumatic  cases  the  history  of 
an  injury  followed  by  shock,  dyspnea,  cyanosis,  intense  pain,  cough, 
thirst,  and  hiccough  may  be  obtained.  The  signs  are  those  of 
pneumothorax,  limited  to  the  lower  chest,  and  displacement  of 
the  heart  to  the  right.  The  tympanitic  note  is  extended  and  inten- 
sified by  distending  the  stomach  or  the  colon  with  air,  and  perhaps  re- 
placed by  dulness  when  these  organs  are  filled  with  water.  Litten  's 
sign  is  usually  absent.  The  X-ray  shows  the  displacement  of  the 
heart,  an  irregular  or  incomplete  diaphragmatic  shadow,  and  a  clear 
area  above  the  line  of  the  diaphragm,  through  which  area  the  mottled 
shadow  of  the  lung  may  be  seen.  This  clear  area  may  be  rendered 
dense  by  injecting  barium  into  the  stomach  or  the  colon.  With 
the  fluoroscope  a  paradoxical  movement  of  the  diaphragm  may  be 
observed,  i.e.,  during  inspiration  the  affected  side  ascends  while 
the  normal  side  descends,  during  expiration  the  affected  side  descends 
while  the  normal  side  ascends.  If,  however,  the  abdominal  muscles 
are  strongly  contracted  during  expiration  the  aft'ected  side  of  the 
diaphragm  is  forced  upwards.  The  diagnosis  has  been  made  before 
operation  or  death  is  only  15  of  the  160  cases  reported  (Giffin).  but 
if  the  possibility  of  diaphragmatic  hernia  is  kept  in  mind  and  all 
suspected  cases  are  carefully  studied  this  condition  should  be  recog- 
nized more  often  in  the  future.  Diaphragmatic  hernia  may  be 
confused  with  pneumothorax  and  elevation  of  the  diaphragm. 
In  pneumothorax  the  tympany  usually  extends  over  the  whole 
thorax,  and  is  uninfluenced  by  distention  of  the  stomach  or  the 
colon  with  air  or  water.  The  breath  sounds  may  be  amphoric, 
distant,  or  absent,  while  in  diaphragmatic  hernia  the  breath  sounds 


ABDOMEN  819 

and  vocal  fremitus  may  be  present,  and  the  metallic  tinkling  coin- 
cides with  the  peristaltic  movements  of  the  stomach  or  intestine 
rather  than  with  respiration.  The  coin  test  is  positive  more  fre- 
quently in  pneumothorax,  and  repeated  vomiting  less  apt  to  occur. 
A  skiagram  will  show  an  intact  diaphragm,  and  no  change  in  the 
clear  area  after  a  bismuth  meal.  Elevation  of  the  diaphragm  is  a 
condition  in  which  one  side  of  the  diaphragm  usually  the  left,  is 
much  higher  than  normal.  It  may  be  transient,  probably  as  the 
result  of  some  temporary  affection  of  the  phrenic  nerve,  or  perma- 
nent. It  is  differentiated  from  diaphragmatic  hernia  by  means  of 
the  X-ray.  The  diaphragmatic  shadow,  though  elevated,  is  normal 
in  outline,  and  beneath  it  are  the  shadows  of  the  stomach  and  the 
colon. 

The  treatment  consists,underintratrachcalinsufflationanesthesia, 
in  opening  the  lower  part  of  the  thorax,  possibly  by  reflecting  a 
section  of  the  eighth  and  the  ninth  ribs,  reducing  the  hernia,  and 
suturing  the  wound. in  the  diaphragm.  If  the  opening  is  too  large 
to  be  sutured  it  may  be  patched  with  a  free  transplant  of  fascia  lata. 
In  most  of  the  cases  of  diaphragmatic  hernia  in  which  the  abdomen 
has  been  opened  in  order  to  deal  with  an  intestinal  obstruction  of 
unknown  origin  the  diaphragm  has  been  closed  from  below.  Even 
in  these  cases  it  would  perhaps  be  better,  after  the  diagnosis  has 
been  established  by  abdominal  section,  to  open  the  thorax,  since 
reduction  of  the  hernia  and  suture  of  the  orifice  are  thus  facilitated. 
Scudder  collected  53  operations,  11  thoracic,  42  abdominal;  14  of 
the  patients  recovered. 

2.  Retroperitoneal  hernia  occurs  in  the  following  situations: 
(a)  Foramen  of  Winslow.  (b)  Recessus  duodeno-jejunalis;  the 
margin  of  this  fossa  contains  the  inferior  mesenteric  vein  or  coHca 
sinistra  artery,  a  fact  to  be  remembered  if,  in  a  case  of  strangulated 
hernia  in  this  vicinity,  enlargement  of  the  opening  is  necessary, 
(c)  Pericecal  fossae,  of  which  theie  are  three,  the  retrocecal,  behind 
the  cecum  and  external  to  the  mesoappendix;  the  superior  ileocecal, 
in  the  upper  angle  formed  by  the  junction  of  the  ileum  and  cecum; 
and  the  inferior  ileocecal,  in  the  lower  angle  formed  by  the  ileum  and 
cecum,  (d.)  Intersigmoid  fossa,  at  the  root  of  the  mesocolon  on  the 
left  side,  (e.)  Retrovesical  fossa.  A  retroperitoneal  hernia  rarely 
causes  trouble  unless  it  become  strangulated,  when  the  symptoms 
are  those  of  intestinal  obstruction.  The  treatment  is  laparotomy 
and  reduction  of  the  hernia.  Obliteration  of  the  hernial  orifice 
by  sutures  may  be  attempted  in  suitable  cases. 


820  MANUAL    OF    SURGFRY 


ACCIDENTS  OF  HERNIA 


Irreducible  hernia  that  is  not  inflammed,  incarcerated,  or  stran- 
gulated presents  all  the  signs  of  a  reducible  one,  except  that  it 
cannot  be  replaced  within  the  abdomen  and  is  apt  to  be  more  firm 
in  consistence.  Irreducibility  is  most  frequent  in  umbilical  hernia? 
(of  adults),  then  in  femoral,  then  in  large  scrotal  hernias.  The 
causes  are:  i.  Adhesions  (a)  between  the  contents  and  the  sac, 
(b)  among  the  contents,  forming  a  mass  which  will  not  pass  through 
the  ring,  (c)  giving  rise  to  cystic  accumulations,  or  (d)  causing 
thickening  of  the  neck  or  other  portion  of  the  sac.  2.  Excessive 
deposit  of  fat,  either  in  the  herniated  omentum  or  mesentery,  or 
within  the  abdomen,  in  the  latter  instance  the  hernia  cannot  be 
returned  because  of  want  of  room.  An  irreducible  hernia  resulting 
from  the  causes  just  mentioned  is  always  liable  to  become  inflamed, 
incarcerated,  or  strangulated. 

The  treatment  in  most  cases  is  operation;  when  this  is  inadvisable 
because  of  the  general  condition  of  the  patient,  the  hernia  may  be 
supported  by  a  bag  truss.  When  due  to  fat,  the  hernia  may  again 
become  reducible  after  strict  dieting. 

An  inflamed  hernia  is  one  in  which  there  is  a  localized  peritonitis, 
involving  the  sac  and  possibly  the  peritoneal  covering  of  the  con- 
tained viscera.  The  causes  are  external,  e.g.,  blows,  badly  fitting 
trusses,  and  strenuous  taxis;  and  internal,  e.g.,  inflammation; 
ulceration,  or  perforation  of  a  herniated  appendix  or  coil  of  bowel, 
peritonitis  arising  within  the  abdomen  and  extending  to  the  sac; 
also  incarceration  and  strangulation,  but  these  are  considered  in 
separate  classes.  The  symptoms  are  pain,  tenderness,  swelling, 
increased  heat,  sometimes  redness  and  edema  of  the  skin  and  occa- 
sionally suppuration;  in  addition  there  are  general  fever  and  often 
vomiting  and  constipation.  The  hernia  is  likely  to  be  irreducible 
and  hence  strangulation  is  strongly  suggested,  but  in  the  latter  there 
are  shock  instead  of  fever,  absence  of  an  impulse  on  coughing, 
absolute  constipation,  and  fecal  vomiting.  The  treatment  is  im- 
mediate operation,  on  the  hernia  in  those  cases  depending  upon 
external  causes  or  causes  within  the  sac,  or  on  the  primary  lesion  in 
those  depending  upon  an  intraabdominal  infection. 

Incarcerated  or  obstructed  hernia  is  an  irreducible  hernia  in 
which  the  fecal  (not  the  blood)  circulation  is  interrupted.  It  is 
generally  due  to  undigested  food  or  impacted  feces.  It  is  most 
common  in  umbilical  hernias,  because  of  the  frequency  of  adhesions, 
which  interfeie  with  peristalsis,  and  because  of  the  presence  of  the 


ABDOMEN  821 

transverse  colon,  which  contains  solid  feces.  The  ^iymptoms  are 
those  of  an  irreducible  hernia  which  becomes  tender  and  painful, 
harder  and  larger  than  usual,  and  dull  on  percussion;  it  may  be 
diminished  in  size  by  pressure,  and  has  an  impulse  on  coughing. 
The  abdomen  becomes  distended  and  there  are  vomiting  (not  fecal) , 
constipation  (not  absolute),  and  colicky  pain.  The  hernia  may 
become  inflamed  or  strangulated.  The  treatment  is  operation, 
unless  the  patient  is  old,  or  in  poor  condition  from  some  independent 
affection,  when  gentle  taxis,  may  be  tried,  but  even  under  these 
circumstances  if  treatment  is  not  quickly  successful,  or  if  symptoms 
of  strangulation  ensue,  operation  should  be  performed. 

Taxis  or  the  manipulations  for  the  reduction  of  a  hernia,  should 
always  be  gentle,  because  of  the  danger  of  rupture  of  the  bowel. 
It  should  not  be  employed  in  the  presence  of  inflammation  or 
strangulation.  Reduction  is  facilitated  by  having  the  patient 
recumbent,  the  thighs  flexed  (and  that  of  the  affected  side  adducted 
in  femoral  or  inguinal  hernia),  and  the  pelvis  raised.  The  adminis- 
tration of  opium  and  belladonna  and  the  application  of  heat  also 
are  useful  in  securing  relaxation.  One  hand  is  used  to  steady  the 
neck  of  the  sac,  while  with  the  other  the  hernia  is  compressed  and 
pushed  back  into  the  abdomen.  In  direct  inguinal  and  umbilical 
hernia  the  pressure  is  backwards ;  in  oblique  inguinal  hernia  upwards, 
outwards,  and  backwards;  in  femoral  hernia  at  first  downwards 
and  inwards,  then  upwards  and  backwards.  The  successful  re- 
duction of  bowel  is  sudden  and  accompanied  by  a  gurgle;  omentum 
is  forced  back  slowly  without  gurgling.  The  continuance  of  symp- 
toms after  apparent  reduction  may  be  due  to  (i)  incomplete  reduction, 
(2)  reduction  en  masse  (see  "Interstitial  Hernia"),  (3)  recurrence 
of  the  hernia,  (4)  the  presence  of  some  other  form  of  intestinal 
obstruction,  (5)  paralysis  of  the  bowel,  (6)  peritonitis,  (7)  reduction 
of  gangrenous  or  perforated  bowel,  (8)  reduction  of  bowel  which 
is  obstructed  by  adhesions  or  through  a  slit  in  the  omentum,  or  to 
(9)  the  effects  of  an  anesthetic,  which,  it  must  be  added,  should 
not  be  employed  unless  one  intends  to  perform  herniotomy.  With 
the  exception  of  the  last  named  condition,  the  persistence  of  symp- 
toms after  apparent  reduction  calls  for  operation. 

Strangulated  hernia  is  one  in  which  the  contents  are  so  firmly 
constricted  that  the  circulation  of  blood  is  cut  off.  Interference  with 
the  fecal  circulation  is  usual  but  not  essential,  since  the  hernia 
may  be  an  epiplocele  or  a  Richter's  hernia. 

The  cause  of  strangulation  is  sudden  augmentation  in  the  size 
of  the  hernia,  from  the  extrusion  of  additional  contents,  from  con- 


82  2  MANUAL    OF    SURGERY 

gestion  or  inflammation,  or  from  fecal  or  gaseous  accumulations. 
In  adults  the  varieties  of  hernia  in  which  strangulation  is  most 
likely  to  occur  are  the  indirect  inguinal,  the  femoral,  the  umbiHcal, 
and  the  postoperative.  The  smaller  the  orifice  the  greater  the 
chance  of  its  gripping  an  extruded  coil  of  bowel;  a  pure  epiplocele  is 
seldom  caught.  Strangulation  is  infrequent  in  children,  and  rare 
in  epigastric  hernia  and  direct  inguinal  hernia.  The  site  of  con- 
striction is  usually  the  hernial  orifice,  but  it  may  be  in  the  neck  of 
the  sac  alone,  or  elsewhere  in  the  sac  as  the  result  of  adhesions  or 
constrictions.  At  this  point  the  intestine  is  furrowed  and,  if  the 
constriction  has  lasted  long  enough,  ulcerated.  Occasionally  this 
ulcerated  area  perforates  after  reduction  of  the  bowel,  or  by  healing 
causes  an  annular  stricture  and  intestinal  obstruction.  The  strangu- 
lated loop  is  distended  with  gas,  and  varies  in  appearance  according 
to  the  degree  and  the  duration  of  the  strangulation.  In  the  first 
stage,  in  which  the  venous  circulation  only  is  affected,  the  gut  wall 
is  thickened  from  congestion  and  edema,  dark  red  in  color,  smooth 
and  elastic  to  the  touch,  and  glistening  in  appearance,  although  in 
places  small  ecchymoses  may  be  seen.  The  vessels  can  be  emptied 
by  pressure,  and  refill  promptly  when  the  pressure  is  removed.  In 
this  stage  relief  of  the  constriction  is  followed  by  complete  recovery 
of  the  gut.  Later,  owing  to  the  swelling  of  the  hernial  contents, 
the  arterial  circulation  is  arrested,  and  this  leads  to  moist  gangrene. 
The  gut  becomes  sodden,  black,  lusterless;  the  vessels  are  throm- 
bosed and  cannot  be  emptied  by  pressure;  and  bacteria  escape  in 
large  numbers  through  the  intestinal  wall.  Finally  perforation 
may  occur,  either  spontaneously  or  as  the  result  of  manipulations. 
The  changes  in  the  bowel  above  and  below  the  seat  of  strangulation 
are  identical  with  those  in  other  forms  of  acute  obstruction  (see 
intestinal  obstruction).  Even  when  obstruction  is  not  complete, 
e.g.,  in  a  Richter's  hernia,  the  bowel  may  be  paralyzed.  The  sac 
is  inflamed,  owing  to  the  passage  of  bacteria  through  the  intestinal 
walls,  and  usually  contains  fluid,  which  is  at  first  clear,  but  in  the 
later  stages  becomes  bloody  and  finally  dark  brown  in  color  and 
offensive  in  odor.  Sloughing  of  the  sac  is  rarely  seen;  it  may  be 
due  to  the  inflammation  or  to  strangulation  of  the  sac.  The  parts 
about  the  sac  are  usually  unaffected,  but  occasionally  in  unrelieved 
cases  they  become  inflamed  and  break  down,  thus  leading  in  rare 
instances  to  spontaneous  cure  by  the  formation  of  an  artificial  anus. 
Retrograde  strangulation  is  a  condition  in  which  the  end  of  a  piece 
of  bowel  or  omentum  in  a  hernia  passes  back  into-  the  abdomen, 
becoming  strangulated  at  the  hernial  orifice,  the  remaining  portion 


ABDOMEN  823 

of  the  hernia  being  uninvolved.  Doubtless  some  of  the  cases  of 
so-called  retrograde  strangulation  are  due  to  the  escape  of  two  coils 
of  intestine  (hernia  en  W),  the  connecting  loop  within  the  abdomen 
becoming  strangulated;  to  the  reduction  of  a  strangulated  segment. 
the  sac  then  filling  with  healthy  bowel  or  omentum;  or  twisting  of  the 
end  that  reenters  the  abdomen. 

The  symptoms  are  those  of  inleslinal  obstruction,  viz.,  shock, 
abdominal  pain  and  distention,  vomiting  which  finally  becomes 
stercoraceous,  increased  peristalsis,  and  absolute  constipation.  In 
the  final  stage  the  picture  is  that  of  generalized  peritonitis.  In  even 
a  strangulated  Richter's,  Littre's,  or  omental  hernia,  there  may  be 
symptoms  of  complete  obstruction,  possibly  from  reflex  paralysis  of 
the  intestine.  The  hernia  is  irreducible,  tense,  tender,  and  painful, 
and  has  no  impulse  on  coughing.  With  the  onset  of  gangrene  pain 
and  tenderness  disappear,  and  the  hernia  becomes  softer  and  some- 
times crepitates.  Two  facts  must  be  emphasized.  First,  the 
symptoms  may  be  mild  and  the  cause  overlooked,  especially  in  old 
women  who  have  long  had  a  small  irreducible  femoral  hernia  that 
they  deem  of  no  importance  and  do  not  mention  to  the  physician, 
or  who  have  a  small  umbilical  hernia  that  is  concealed  beneath  a 
thick  layer  of  fat.  In  all  doubttul  cases  one  should  not  only  inquire, 
but  look  for  hernia.  Secondly,  gangrene  depends,  not  so  much  on 
the  duration,  as  on  the  tightness  of  the  strangulation,  hence  may 
occur  in  a  few  hours. 

The  treatment  is  immediate  operation.  If  the  circulation  in  the 
afTected  loop  of  bowel  is  really  suppressed,  taxis  is  contraindicated. 
In  many  instances  in  which  a  so-called  strangulated  hernia  has  been 
replaced  without  evil  affects  following,  the  temporary  irreducibility 
was  the  result  of  incarceration,  not  strangulation,  the  dift'erentiation 
symptomatically,  between  these  conditions  often  being  difficult, 
sometimes  impossible. 

Operation  for  incarcerated  and  strangulated  hernia,  or  herni- 
otomy, as  it  is  sometimes  called,  should  be  preceded  by  gastric  lavage, 
especially  when  a  general  anesthetic  is  to  be  given.  Local  anesthesia 
is  much  safer,  if  the  patient  is  in  poor  condition.  The  cutaneous 
incisions  suitable  for  the  various  forms  of  hernia  have  already  been 
described.  The  sac  is  recognized  by  its  bluish  color,  the  presence 
of  subperitoneal  fat,  and  by  its  gliding  over  the  contained  viscera. 
It  almost  always  contains  fluid,  hence  can  be  opened,  unless  there  are 
adhesions,  without  much  danger  of  injuring  the  bowel.  The  nail  of 
the  left  forefinger  is  insinuated  within  the  stricture,  which  is  nicked 
sufficiently  to  release  the  gut,  with  blunt  pointed  scissors  or  a  hernia 
knife  (curved  blunt-ended  bistoury)    introduced  along  the  linger. 


824  MANUAL    OF    SURGERY 

In  inguinal  hernia  the  direction  of  the  nick  is  directly  upwards,  in 
femora]  hernia  directly  inwards.  Many  surgeons  divide  the  con- 
stricting tissues  from  the  surface  towards  the  hernia,  so  that  if  any 
important  vessels  are  cut  they  may  be  caught  at  once  and  tied. 
The  bowel  must  be  carefully  examined  to  ascertain  whether  it  is 
viable  or  not,  and  it  should  be  withdrawn  a  little  from  the  abdomen, 
in  order  to  deterinine  its  condition  at  the  point  of  constriction  and  to 
make  sure  there  is  no  retrograde  strangulation  or  torsion;  the  omen- 
tum should  be  treated  in  a  like  manner.  The  bowel  is  viable  if  it 
retains  its  normal  luster  and  elasticity,  if  the  arteries  pulsate,  if  the 
veins  can  be  emptied  by  pressure  and  refill  promptly  when  the  pres- 
sure is  removed,  if  peristalsis  can  be  induced  by  pinching,  and  if  the 
color,  although  bluish  or  dark  red,  improves  quickly  on  the  applica- 
tion of  hot  water.  The  bowel  is  gangrenous  if  it  is  lusterless,  black, 
sodden;  if  the  arteries  do  not  pulsate;  and  if  the  veins  are  throm" 
bosed.  Between  these  extremes  there  are  numerous  gradations, 
and  in  some  cases  even  an  experienced  surgeon  is  unable  to  say 
whether  the  bowel  will  live  or  not.  If  the  hernial  contents  are 
healthy,  they  should  be  replaced,  and  the  radical  operation  per- 
formed if  the  patient's  condition  permits.  Any  small  ulcer  at  the 
site  of  constriction  should  be  inverted  with  Lembert  sutures.  If  the 
bowel  is  gangrenous  it  should  be  resected,  taking  care  to  go  well  above 
and  below  the  apparent  limits  of  the  gangrene,  else  sloughing  at  the 
site  of  anastomosis  may  follow.  In  femoral  hernia  it  will  usually  be 
necessary  to  make  a  second  incision  above  Poupart's  ligament  for 
this  purpose.  If  the  patient's  condition  forbids  resection,  the  bowel 
may  be  opened  and  an  artificial  anus  established ;  this  is  dealt  with  at 
a  later  period  as  described  elsewhere.  If  the  condition  of  the  bowel 
is  doubtful,  it  should  be  resected  if  the  surgeon  is  skillful  and  the 
patient's  condition  good;  under  other  circumstances  it  may  be 
surrounded  with  gauze  and  the  wound  left  open.  Should  gangrene 
or  perforation  follow,  the  intestinal  contents  will  be  discharged 
through  the  wound;  if  gangrene  does  not  supervene,  the  bowel  may 
be  replaced  and  the  wound  closed  at  a  later  period.  When  the 
condition  of  the  omentum  is  doubtful,  it  should  be  removed.  The 
mortality  mounts  from  about  5  per  cent,  when  the  herniotomy 
is  done  within  a  few  hours  of  the  onset  of  the  strangulation  up  to 
50  per  cent,  when  done  on  the  third  day,  after  which  recovery  is 
exceptional.  Sometimes  blood  appears  in  the  stools  after  operation, 
and  although,  as  a  rule,  of  no  serious  import,  such  an  occurrence 
always  causes  anxiety,  since  it  may  be  due  to  thrombosis  or  deep 
ulceration.  Rarely  a  cicatricial  stricture  develops  at  the  site  of  the 
original  constriction. 


CHAPTER  XXVIII 
RECTUM  AND  ANUS 

Since  rectal  symptoms,  and  indeed  rectal  diseases,  may  be  due  to, 
or  associated  with,  affections  of  the  genito-urinary  apparatus, 
it,  too,  should  be  reviewed  when  the  rectum  and  anus  are  investi- 
gated . 

Examination  of  the  anus  and  rectum  may  be  made  in  the  Sims, 
knee-chest,  lithotomy,  or  squatting  position,  or  with  the  patient 
standing  and  bending  over  the  back  of  a  chair.  A  preliminary 
examination,  before  the  use  of  laxatives  or  enemata,  will  reveal  the 
character  of  any  feces  or  discharge  that  may  be  present  (pus,  blood, 
mucus,  etc.).  The  external  parts  may  then  be  cleansed  and  the 
rectum  emptied  with  an  enema. 

Inspection  of  the  external  parts  may  reveal  the  orifice  of  a  fistula, 
external  piles,  protruding  internal  piles,  fissure,  skin  diseases,  abscess, 
condylomata,  mucous  patches,  parasites  on  the  anal  hairs,  anal 
tumors,  and  similar  conditions.  By  separating  the  buttocks  and 
having  the  patient  strain,  internal  piles,  polypi,  or  a  procidentia  may 
appear. 

Digital  examination  permits  exploration  of  the  lower  four  inches 
of  the  rectum.  A  rubber  glove  should  always  be  worn,  and  the 
index  finger,  lubricated  with  sterile  vaselin  (light  oil  or  lubricating 
fluids  cause  more  pain),  introduced  gently,  first  upwards  and  for- 
wards towards  the  umbilicus,  until  the  internal  sphincter  is  passed, 
then  backwards  in  the  hollow  of  the  sacrum.  The  sphincter  is 
twitching  and  spasmodic  in  an  acute  lesion  of  the  anus;  hard,  un- 
yielding, and  hypertrophied  in  chronic  disease;  relaxed  in  exhausting 
general  maladies.  The  finger  may  detect  an  abscess,  an  ulceration,  a 
foreign  body,  a  tumor,  a  stricture,  indurated  internal  hemorrhoids, 
procidentia,  or  the  internal  orifice  or  the  tract  of  a  fistula.  A  growth 
just  beyond  the  reach  of  the  finger  may  become  palpable  if  pressure 
is  made  on  the  lower  abdomen  with  the  other  hand  (bimanual  exami- 
nation), or  if  the  patient  strains  while  in  the  squatting  posture. 
The  coccyx,  the  prostate,  the  seminal  vesicles,  the  female  perineum 
and  pelvic  organs  also  must  be  investigated. 

Instrumental  examination  of  the  anal  canal  and  the  lower  rectum 
can  be  made  with  a  short  rectal  speculum  of  the  cylindric  or  valvular 
type  [proctoscope) ,  but  for  inspection  of  the  upper  rectum  and  the 

82s 


826 


MANUAL    OF    SURGERY 


sigmoid  the  sigmoidoscope,  preferably  that  devised  by  Tuttle,  is 
needed.  Tuttle's  instrument  is  a  long  hollow  cylinder  with  an  elec- 
tric lamp  at  the  distal  end.  The  patient  assumes  the  knee-chest 
posture,  and,  with  the  obturator  in  position,  the  "scope"  is 
introduced  through  the  anus,  towards  the  umbihcus,  until  the 
internal  sphincter  is  passed.  The  obturator  is  then  withdrawn,  and 
if  the  rectum  fails  to  distend  under  atmospheric  pressure,  a  plug, 
containing  a  glass  window,  is  inserted  in  the  proximal  end  of  the 
instrument,  and  the  inflation  made  by  means  of  a  hand  bulb,  which  is 
connected  with  a  small  tube  running  through  the  plug.  The  instru- 
ment may  then  be  passed  to  its  lull  extent,  fourteen  inches,  under 
guidance  of  the  eye.  Long  applicators,  forceps,  etc.,  are  made  tor 
diagnostic  or  therapeutic  manipulations  through  the  sigmoidoscope. 
Probing  is  employed  chiefly  for  the  diagnosis  of  fistula.  The  size  and 
the  shape  of  the  rectum,  or  of  rectal  sinuses  or  diverticula,  can 


Fig.  460. — Imperforate  anus. 


Fig.  461. — Imperforate  rectum. 


be  demonstrated  with  the  X-ray,  after  the  injection  of  a  barium 
mixture. 

Congenital  Malformations. — Normally,  in  the  early  stages  of 
development  the  hind-gut  communicates  in  front  with  the  allantois 
and  behind  with  the  neurenteric  canal.  At  a  later  period  the  gut  and 
the  genitourinary  canal  open  externally  in  a  common  passage, 
called  the  cloaca.  By  the  growth  of  a  posterior  and  two  lateral  folds, 
the  perineum  is  formed,  and  the  gut  separated  from  the  genito- 
urinary cavity.  A  pit  called  the  proctodeum  extends  inward  from 
the  perineum,  until  finally  it  meets  and  communicates  with  the 
rectum.  According  to  the  extent  to  which  development  has  pro- 
gressed, the  following  malformations  may  be  encountered.  Anal 
stricture  may  be  enlarged  by  cutting  backwards  towards  the  coccyx, 
and  the  opening  maintained  by  the  subsequent  passage  of  bougies. 
Imperforate  anus  (Fig.  460)  is  a  condition  in  which  the  rectum  is 
developed,  but  there  is  no  proctodeum.     When  the  infant  cries,  the 


RECTUM    AND    ANUS 


827 


rectum  is  felt  to  bulge  at  the  point  where  the  anal  oriiice  should 
he.  Imperforate  rectum  (Fig.  461),  in  which  both  the  rectum  and 
the  proctodeum  are  developed,  but  have  not  united,  is  the  most 
common  malformation,  the  septum  being  about  an  inch  above  the 
anus.  Absent  rectum  (Fig.  462)  is  a  malformation  in  which  the 
rectum  ends  blindly  high  up,  perhaps  above  the  pelvic  brim.  The 
proctodeum  may  or  may  not  be  present.     When  the  septum  which 


Fig.  462. — Absent  rectum. 


Atresia  ani  vesicalis. 


should  divide  the  cloaca  is  defective  the  rectum  may  open  into  the 
bladder  (atresia  ani  vesicalis,  Fig.  463),  urethra  (atresia  ani  ure- 
thralis,  Fig.  464),  or  vagina  (atresia  ani  vaginalis,  Fig.  465). 

The  treatment  in  all  cases,  except  anal  stricture  {vide  supra)  and 
atresia  ani  vaginalis,  must  be  prompt,  otherwise  the  patient  dies 
of  intestinal  obstruction.     If  no  anus  is  present,  an  incision  is  made 


Fig.  464. — Atresia  ani  urethralis. 


Fig.  465. — Atresia  ani  vaginalis 


in  the  midline  of  the  perineum  and  deepened  until  the  rectum  is 
encountered,  care  being  taken  not  to  injure  the  bladder.  One  may 
follow  the  concavity  of  the  sacrum  as  high  as  its  promontory,  excis- 
ing, when  necessary,  the  coccyx  and  lower  segment  of  the  sacrum; 
when  the  rectum  is  found,  it  is  pulled  down  to  the  external  opening, 
incised,  and  stitched  to  the  skin.  If  the  rectum  cannot  be  found, 
the  sigmoid  may  be  brought  down  into  the  wound,  or  an  artificial 


828  MANUAL    OF    SURGERY 

anus  made  in  the  inguinal  region.  When  the  anus  is  present,  the 
septum  separating  it  from  the  rectum  should  be  incised  or  excised, 
the  opening  thus  formed  being  maintained  by  the  passage  of  bougies. 
In  atresia  ani  vaginalis  the  feces  escape  without  hindrance,  hence 
operation  may  be  postponed  until  the  infant  is  several  years  old. 
The  rectum  is  detached  from  the  vagina  and  fastened  to  the  perineum 
and  the  opening  in  the  vagina  closed  with  sutures. 

Injuries  of  the  rectum  are  usually  caused  by  falHng  on  a  pointed 
object,  e.g.,  a  spike,  by  the  breaking  of  a  china  bedroom  utensil, 
by  childbirth  (see  "Lacerations  of  the  Perineum"  and  "Rectovaginal 
Fistula"),  by  gunshot  or  bayonet  wounds,  by  fractures  of  the  pelvis, 
and  by  foreign  bodies  {vide  infra).  The  rectum  may  be  wounded 
during  operations,  e.g.,  perineorrhaphy,  prostatectomy,  perineal 
section,  divulsion  of  the  sphincter,  reduction  of  rectal  prolapse,  and 
pelvic  operations,  also  by  the  passage  of  a  urethral  or  a  rectal  bougie, 
a  proctoscope,  or  an  enema  nozzle,  particularly  if  the  bowel  is  friable, 
e.g.,  from  carcinomatous  infiltration.  The  rectum  has  been  ruptured 
by  the  colpeurynter,  by  the  injection  of  compressed  air,  and  by  the 
introduction  of  the  hand  for  diagnostic  purposes.  The  symptoms 
are  pain,  hemorrhage,  and  in  most  cases  shock;  the  complications 
sepsis,  periproctitis,  peritonitis,  and  secondary  hemorrhage;  the 
sequelae  stricture,  incontinence,  and  the  various  forms  of  fistula. 
The  treatment  should  be  preceded  by  a  careful  examination  to  deter- 
mine the  extent  of  the  wound,  bearing  in  mind  the  possibility  of 
injury  to  the  urethra,  bladder,  vagina,  and  small  intestine.  In 
uncompHcated  wounds  of  the  rectum  above  the  sphincters  and  below 
the  peritoneum  the  sphincters  should  be  dilated,  the  parts  irrigated 
with  salt  solution,  the  wound  sutured  with  catgut,  and  a  short  rubber 
tube,  covered  with  vaselinized  gauze,  inserted  through  the  anus  to 
lessen  intrarectal  tension,  which  might  force  fecal  matter  into  the 
perirectal  cellular  tissues.  Injuries  to  adjacent  viscera  should  be 
repaired  as  described  in  the  sections  dealing  with  those  viscera. 

Foreign  bodies  that  have  been  swallowed,  that  have  formed  in,  or 
ulcerated  into,  the  intestine  (see  "Foreign  Bodies  in  the  Intestine"), 
or  that  have  been  introduced  through  the  anus  by  degenerates, 
lunatics,  or  criminals,  may  be  found  in  the  rectum.  The  symptoms 
are  tenesmus,  the  passage  of  blood  and  mucus  (owing  to  ulceration) , 
and  possibly  obstruction  or  suppurative  periproctitis.  Large  foreign 
bodies  may  press  on  the  bladder  and  cause  frequent  micturition,  or 
on  the  sacral  plexus  and  cause  shooting  pains  in  the  lower  extremities. 
The  diagnosis  may  be  made  with  the  finger,  the  speculum,  or  the  X- 
ray.     The  treatment  is  extraction  with  the  finger  or  with  forceps. 


RECTUM    AND    ANUS  829 

In  some  cases  it  may  be  necessary  to  give  a  general  anesthetic  and 
split  the  anal  canal  backwards  towards  the  coccyx.  When  the  foreign 
body  is  impacted  up  near  the  sigmoid  it  may  be  safer  to  y)erform 
la]iar()t(.)my  and  rem()\'e  it  from  above. 

Pruritus  ani,  or  itching,  is  a  symptom  which  may  be  caused  by 
local  conditions,  such  as  piles,  fissure,  fistula,  proctitis,  worms, 
pediculi,  uncleanliness,  herpes,  eczema,  and  diseases  of  the  urethra, 
bladder,  prostate,  vagina,  uterus,  or  ovaries,  or  by  general  conditions 
like  gout,  disorders  of  digestion,  nephritis,  diabetes,  jaundice,  con- 
stipation, mental  and  nervous  disorders,  and  the  opium,  alcohol, 
tea,  and  tobacco  habits.  The  treatment  is  removal  of  the  cause  and 
attention  to  the  general  health.  The  parts  should  be  kept  scrupu- 
lously clean.  The  itching  may  be  relieved  by  lotions  or  ointments 
containing  carbolic  acid  (1-15)  or  menthol  (1-30),  or  by  painting  the 
skin  with  silver  nitrate  (i-io)  or  compound  tincture  of  benzoin; "in 
the  worst  cases  the  sensory  nerves  supplying  the  part  may  be  in- 
jected with  alcohol  or  divided,  or  the  affected  skin  excised. 

Fissure  of  the  anus  is  caused  by  the  passage  of  hardened  feces, 
and  not  infrequentl}^  accompanies  hemorrhoids  and  other  local  dis- 
eases. It  is  usually  at  the  posterior  margin  of  the  anus,  and  there  is 
often  a  "sentinel"  external  pile  at  its  outer  extremity.  The  principal 
symptom  is  burning  pain  on  defecation,  and  sometimes  on  walking  or 
coughing.  Constipation  is  thus  encouraged,  and  when  the  hardened 
feces  pass,  they  may  be  streaked  with  pus  or  blood.  The  ulcer  is 
seen  on  separating  the  folds  of  the  anus  and  the  sphincter  is  found 
spasmodically  contracted.  The  treatment  is  laxatives  and  the  appli- 
cation of  silver  nitrate;  if  this  fails,  the  patient  should  be  anesthe- 
tized, and  the  sphincter  stretched  with  the  thumbs,  thus  causing 
a  paralysis  for  from  five  to  ten  days,  during  which  time  the  ulcer 
heals.  The  same  result  may  be  secured  by  dividing  the  superficial 
fibers  of  the  external  sphincter  through  the  base  of  the  ulcer.  Piles 
should,  of  course,  be  removed  at  the  same  time.  Large  ulcers  may 
be  excised. 

Proctitis,  or  inflammation  of  the  rectum,  arises  from  foreign 
bodies,  polypi,  piles,  parasites,  gonorrhea,  repeated  catharsis,  irritat- 
ing enemata,  dysentery,  and  other  forms  of  colitis.  The  symptoms 
are  tenesmus,  frequent  bowel  movements,  with  mucus,  pus,  or  blood, 
and  a  sensation  of  heat  and  fullness.  The  bladder  also  may  be 
irritable.  The  rectal  mucous  membrane  may  prolapse,  and  in 
chronic  cases  there  may  be  ulceration  followed  by  stricture  formation. 
By  digital  examination  the  rectum  is  found  to  be  hot  and  tender,  and 
by  inspection  with  the  proctoscope  the  red  and   swollen  mucous 


830 


MANUAL    OF    SURGERY 


membrane  can  be  seen.  The  treatment  is  removal  of  the  cause,  rest 
in  bed,  liquid  diet,  suppositories  of  opium  and  belladonna,  hot  sitz 
baths,  and  irrigation  with  very  weak  solutions  of  silver  nitrate. 

Periproctitis  (cellulitis)  is  usually  caused  by  infection  from  the 
rectum,  as  the  result  of  disease  (piles,  fissure,  fistula,  cancer,  etc.)  or 
injury  (hardened  feces,  swallowed  fish  bone,  etc).  It  may  be  caused 
also  by  abrasions  of  the  skin  and  affections  of  the  surrounding  tissues, 
including  the  bladder,  urethra,  prostate,  and  female  pelvic  organs. 
The  diffuse  form  spreads  rapidly,  results  in  extensive  sloughing,  is 
usually  seen  in  the  old  and  asthenic,  and  is  very  apt  to  cause  death. 
It  is  treated  by  free  drainage  and  vigorous  stimulation.  In  the 
circumscribed  variety  an  abscess  forms  below  (ischiorectal  abscess)  or 
above  the  levator  ani  ('pelvirectal  abscess).  These  abscesses  are 
described  in  the  next  section. 

Abscesses  about  the  anus  and  rectum  occur  chiefly  in  four  situa- 
tions (Fig.  466),  in  and  beneath  the  skin  of  the  anus,  beneath  the 


Fig.  466.- 


-Diagram  of  anorectal  abscesses,      i.   Anal  abscess.      2.   Submucous  abscess. 
3.   Ischiorectal  abscess.     4.   Pelvirectal  abscess. 


mucous  membrane  of  the  rectum,  and,  as  mentioned  in  the  preceding 
paragraph,  in  the  perirectal  cellular  tissue  below  (ischiorectal  ab- 
scess) or  above  the  levator  ani  (pelvirectal  abscess). 

An  anal  abscess  is  due  to  infection  of  a  hair  foUicle  or  a  sebaceous 
gland  (follicular  abscess,  really  a  furuncle),  or  to  a  fissure  or  a  sup- 
purating external  hemorrhoid  {marginal  abscess).  Follicular  ab- 
scesses, like  boils  elsewhere,  may  be  multiple,  but  seldom  give  rise  to 
fistulae.  A  marginal  abscess  is  generally  single  and  may  cause  a 
fistula  superficial  to  the  external  sphincter.  The  symptoms  are  itching 
and  throbbing  pain,  worse  on  defecation  and  walking.  As  the 
condition  is  superficial  it  is  easily  recognized.  The  treatment  is 
incision,  removal  of  undermined  skin,  disinfection,  drainage.  If 
the  abscess  is  due  to  a  fissure,  or  an  external  pile  extending  into  the 
anal  canal,  the  sphincter  should  be  stretched. 

A  submucous  abscess,  i.e.,  between  the  mucosa  and  the  mus- 


RECTUM    AND    ANUS  83 1 

cularis,  is  generally  the  result  of  a  superficial  injury  by  a  foreign 
body,  or  of  an  ulcerated  polyp  or  hemorrhoid.  The  symptoms  are 
those  of  the  preceding  variety,  and  the  abscess  can  be  felt  by  digital 
examination.  The  treatment  is  divulsion  of  the  sphincter,  incision, 
removal  of  undermined  mucous  membrane,  and,  later,  applications  of 
silver  nitrate.     Gauze  drainage  is  not  needed. 

Acute  ischiorectal  abscess  is  a  form  of  periproctitis,  hence  due  to 
the  same  causes.  Left  to  itself  the  abscess  usually  breaks  through 
the  weakest  portions  of  its  wall,  i.e.,  through  the  skin  along  side  of  the 
anus,  and  through  the  mucous  membrane  towards  the  back  of  the 
anal  canal  (between  the  sphincters)  at  the  point  where  the  posterior 
edges  of  the  levators  ani  join  the  anococcygeal  ligaments,  thus 
forming  a  complete  fistula.  Sometimes  it  burrows  across  the  median 
line  to  the  opposite  ischiorectal  fossa  (horseshoe  abscess).  The 
symptoms  are  throbbing  pain,  intensified  by  coughing,  walking,  sit- 
ting, and  defecation,  sometimes  retention  of  urine,  and  always  con- 
stitutional evidences  of  sepsis.  Between  the  anus  and  the  ischial 
tuberosity  is  a  hot,  red,  tender,  brawny,  and  edematous  induration, 
and  on  passing  the  finger  into  the  anal  canal  a  tender,  elastic  swelling 
can  be  felt  on  the  corresponding  side.  The  treatment  should  be 
prompt,  in  order  to  avoid  the  formation  of  a  fistula.  A  free  antero- 
posterior incision  is  made  between  the  anus  and  the  tuber  ischii, 
and  the  cavity  irrigated  with  salt  solution  and  packed  with  iodoform 
gauze.  The  pus  is  fetid  and  .often  contains  bubbles  of  gas  (colon 
bacillus) ;  it  may  be  thick  and  yellow  or,  from  the  presence  of  altered 
blood  clot,  dark  brown.  Chronic  ischiorectal  abscess  is  usually 
tuberculous,  occasionally  syphilitic.  There  is  at  first  a  painless 
induration,  which  subsequently  softens;  in  the  later  stages  it  is  often 
infected  with  pyrogenic  organisms,  the  symptoms  then  being  those 
of  an  acute  abscess.     The  local  treatment  is  that  of  acute  abscess. 

A  pelvirectal  abscess  is  one  occurring  above  the  levator  ani,  be- 
tween it  and  the  rectum.  This  space  is  continuous  with  the  pelvic 
cellular  tissue,  hence  a  pelvirectal  abscess  is  due  more  often  to  disease 
of  the  urethra,  bladder,  prostate,  or  female  pelvic  organs,  than  to 
affections  of  the  rectum.  Occasionally  a  psoas  or  an  appendiceal 
abscess,  or  an  abscess  proceeding  from  the  pelvic  bone  points  in 
this  region,  and  sometimes  the  pus  perforates  the  levator  ani  and 
appears  in  the  ischiorectal  fossa.  The  symptoms  are  those  of  the 
causative  lesion,  with  painful  defecation  and  sepsis.  The  abscess 
may  be  felt  bulging  into  the  rectum  above  the  level  of  the  internal 
sphincter.  The  treatment  is  that  of  the  cause,  with  divulsion  of  the 
sphincter  and  evacuation  of  the  abscess. 


832 


MANUAL    OF    SURGERY 


Fistula  in  ano  means  not  only,  as  the  term  indicates,  a  iistula 
opening  into  the  anal  canal,  but  also  a  fistula  running  from  the  peri- 
neal skin  to  the  rectum,  or  a  sinus  opening  into  any  portion  of  the 
anorectal  canal  or  upon  the  skin  in  the  neighborhood  of  the  anus. 
Fistulae  connecting  the  rectum  with  other  viscera  (bladder,  vagina, 
etc.),  however,  are  not  included  under  this  heading.  Excepting 
punctured  wounds,  and  the  rare  non-inflammatory  fistula,  lined  by 
epithelium  and  possibly  due  to  a  small  pressure  diverticulum,  fistula 
in  ano  is  always  caused  by  the  breaking  of  an  abscess  through  the 
skin,  through  the  mucous  membrane,  or  in  both  situations,  hence  there 
are  three  varieties,  the  blind  external,  the  blind  internal,  and  the 
complete.  These  suppurating  tracts  refuse  to  heal  because  of  im- 
perfect drainage,  continual  reinfection,  constant  motion,  and,  in  the 
complete  variety,  because  of  the  escape  of  gas  and  feces  through  the 


Fig.  467. — Diagram  of  anorectal  fistulas.  Blind  external  fistulas  following  (i)an 
anal  abscess  and  (2)  an  ischiorectal  abscess.  3.  Sinus  from  disease  of  the  ischium. 
Blind  internal  fistulse  following  (4)  a  submucous  abscess  and  (5)  a  pelvirectal  abscess. 
6.   Complete  fistula  following  an  ischiorectal  abscess. 

tract.  Further,  syphilis  may  be  responsible,  and,  according  to 
some  authorities,  about  one-half  of  the  cases  are  tuberculous.  While 
phthisis  is  present  in  only  a  small  proportion  of  those  submitting  to 
operation,  many  develop  the  disease  subsequently,  hence  the  con- 
clusion that  fistula  in  ano  is  often  the  primary  source  of  tuberculous 
infection. 

The  blind  external  fistula  (really  as  inus)  opens  externally,  but 
does  not  communicate  with  the  bowel.  It  is  short,  subcutaneous, 
and  close  to  the  anus  when  due  to  the  breaking  of  an  anal  abscess; 
deep  and  farther  away  from  the  anus  when  due  to  the  breaking  of  an 
ischiorectal  abscess  (Fig.  467),  many  of  the  so-called  blind  external 
fistula  are,  in  reality,  complete,  the  internal  orifice  being  so  small 
as  to  escape  detection.  If  the  opening  is  in  front  of  the  anus  one 
should  suspect  a  perineal  fistula  (see  "Stricture  of  the  Urethra") ;  if 


RECTUM   AND   ANUS  833 

near  the  tuber  ischii,  disase  of  the  bone;  if  near  the  coccyx,  a  post- 
anal dimple  or  a  suppurating  dermoid. 

The  blind  internal  fistula  (really  a  sinus)  opens  into  the  bowel, 
but  has  no  external  opening.  It  is  comparatively  infrequent,  oc- 
curring in  about  lo  per  cent,  of  the  cases  of  anorectal  fistula.  The 
submucous  form  usually  opens  into  the  anal  canal,  the  pelvirectal 
above  the  internal  sphincter.  In  either  case  the  orifice  is  generally 
on  the  posterior  or  the  lateral  wall  of  the  anorectal  canal;  a  sinus 
opening  on  the  anterior  wall  may  follow  the  breaking  of  a  prostatic 
abscess. 

The  complete  or  true  fistula  opens  both  externally  and  internally. 
It  occurs  in  about  75  per  cent,  of  the  cases  and  is  usually  the  result  of 
an  ischiorectal  abscess,  the  internal  opening  being  between  the  two 
sphincters,  the  external  within  an  inch  and  a  half  of  the  anus.  When 
following  a  pelvirectal  abscess,  however,  the  internal  opening  maybe 
above  the  internal  sphincter,  or  when  following  an  anal  abscess, 
outside  the  external  sphincter.  A  horseshoe  fistula  extends  partly 
around  the  bowel,  accross  the  median  line,  and  opens  externally  on 
each  side;  as  a  rule  there  is  only  one  internal  opening. 

The  symptoms  of  fistula  in  ano  are  pain  during  defecation,  tenes- 
mus, especially  when  there  is  an  internal  opening,  a  purulent  dis- 
charge from  the  anus  or  the  external  opening,  and  in  the  complete 
variety  the  passage  of  feces  and  gas  through  the  fistula;  recurring 
abscesses  may  form,  owing  to  healing  or  blocking  of  the  openings. 
These  abscesses  may  make  new  outlets  for  themselves,  thus  a  blind 
external  or  internal  fistula  may  become  a  complete  fistula,  and  a  com- 
plete fistula  may  establish  numerous  side  tracts  extending  in  various 
directions  (Fig.  468).  When  there  is  an  external  opening,  the  diag- 
nosis is  readily  made  by  inspection  and  the  use  of  a  probe.  When 
there  is  no  external  opening,  it  will  be  necessary  to  use  a  speculum  in 
order  to  expose  the  orifice.  Digital  examination  will  reveal  spasm  of 
the  sphincters,  a  cord-like  area  of  induration  on  one  side  of  the  rec- 
tum, and  possibly  the  internal  orifice  of  the  fistula.  The  lungs 
should  always  be  examined  for  evidences  of  phthisis. 

The  treatment  is  the  conversion  of  the  fistula  into  an  open  wound, 
so  that  it  may  heal  from  the  bottom.  A  grooved  director  is  passed 
through  the  fistula  into  the  rectum,  and  the  overlying  tissues  severed 
with  a  bistoury.  In  order  to  avoid  incontinence  the  external  sphinc- 
ter should  be  cut  but  once,  and  always  at  right  angles  to  its  fibers 
and  the  internal  sphincter  should  never  be  cut.  If  the  fistula  enters 
the  bowel  above  the  internal  sphincter  the  tract  should  be  opened 
into  the  bowel  at  its  lower  part  only.     All  branching  sinuses  likewise 


834 


MANUAL    OF    SURGERY 


should  be  opened,  and  all  fibrous  tissue  and  undermined  skin 
cut  away  with  scissors.  The  bleeding  is  then  checked,  and  the 
wound  packed  with  iodoform  gauze.  If  the  fistula  is  lined  with  mu- 
cous membrane  it  must  be  completely  excised.  A  blind  external  or 
internal  fistula  may  be  converted  into  a  complete  one  and  treated  as 
outlined  above,  or  a  blind  external  fistula  may  be  excised  and  the 
wound  sutured.  The  bowels  are  confined  for  the  first  three  or  four 
days,  and  the  wound  dressed  after  each  defecation,  being  irrigated 
with  salt  solution  and  repacked  with  iodoform  gauze.  Mackensie 
makes  a  large  incision  alongside  of  the  anus,  excises  the  fistula, 
sutures  the  opening  in  the  rectum,  and  then  closes  the  wound  in  the 


Fig.  468. — Multiple  fistulae  in  ano. 

overlying  tissues,  except  at  one  point,  where  a  small  drain  is  inserted. 
This  operation  might  be  of  service  in  some  cases  in  which  the  internal 
opening  of  the  fistula  is  above  the  internal  sphincter.  Elting 
begins  as  in  the  Whitehead  operation  for  piles,  raising  the  cuff  of 
mucous  membrane  to  a  point  above  the  internal  orifice  of  the  fistula; 
when  the  cuff  is  amputated  and  the  margin  of  mucous  membrane 
sutured  to  the  skin. 

Hemorrhoids,  or  piles,  are  swellings  due  to  varicose  veins  about 
the  lower  end  of  the  rectum.  The  causes  are  those  which  induce  con- 
gestion in  this  region,  such  as  sedentary  habits,  rectal  disorders, 
tumors,  inflammatory  affections  in  the  pelvis,  cirrhosis  of  the  liver 
and  other  conditions  which  interfere  with  the  portal  circulation. 


RECTUM    AND    AMUS  835 

diseases  of  the  heart  and  lungs,  and  repeated  straining  efforts  to 
empty  the  bladder  or  the  bowel,  e.g.,  phimosis,  urethral  stricture, 
enlarged  prostate,  vesical  calculus,  and,  most  important  of  all, 
chronic  constipation.  The  hemorrhoidal  veins  pierce  the  muscular 
coat  of  the  rectum,  run  between  it  and  the  mucous  membrane  in  a 
longitudinal  direction,  form  a  plexus  around  and  above  the  anus  and 
constitute  one  of  the  principal  communications  between  the  portal 
and  systemic  circulations;  they  have  but  little  support,  possess  no 
valves,  and  are  massaged  downwards  by  hardened  feces.  There 
are  two  varieties  of  hemorrhoids,  the  external  and  the  internal, 
which,  however,  often  coexist. 

External  hemorrhoids  occur  at  the  margin  of  the  anus,  are  covered 
with  skin,  originate  from  the  inferior  hemorrhoidal  plexus  and  consist 
of  dilated  veins  surrounded  by  librocellular  tissue.  They  cause  no 
symptoms,  except  possibly  itching  or  a  Httle  irritation,  unless  they 
are  inflamed,  when  the  veins  become  thrombosed,  painful,  and  tender 
and  appear  as  tense  bluish  masses  which  cannot  be  emptied  by  pres- 
sure. When  the  attack  subsides,  the  piles  are  harder  and  thicker 
than  before.  The  treatment  is  the  relief  of  constipation,  cleanliness, 
and,  the  use  of  soft  paper  or  cotton,  after  defecation.  The  parts 
may  be  washed  with  a  lotion  containing  witch-hazel.  Operation  is 
rarely  required  unless  the  piles  become  inflamed,  when  they  should 
be  incised,  the  clot  turned  out,  and  the  cavity  filled  with 
gauze.  When  operating  on  internal  hemorrhoids  it  is  advisable 
to  remove  any  coexisting  external  piles  with  scissors,  the  cuts 
radiating  from  the  anus.  If  too  much  skin  is  removed,  however, 
stenosis  may  follow. 

Internal  hemorrhoids  aie  covered  with  mucous  membrane, 
originate  from  the  superior  hemorrhoidal  plexus,  and  consist  of 
dilated  veins,  arterial  twigs,  and  connective  tissue.  They  cause 
pain,  a  sense  of  fullness,  and  often  bleeding  and  a  mucous  discharge. 
They  may  protrude  through  the  anus,  and  in  some  cases  become 
strangulated  from  the  grip  of  the  sphincter  and  undergo  sloughing. 
When  inflamed  (attack  of  piles),  they  swell  and  become  intensely 
painful.  Ulceration  or  suppuration,  and  occasionally  abscess  of  the 
liver  or  pyemia  may  follow.  The  diagnosis  is  easily  made  with  the 
speculum,  but  one  must  examine  the  whole  rectum  in  order  to  exclude 
carcinoma. 

The  treatment  is  removal  of  the  cause,  if  such  be  possible.  Alco- 
hol and  spices  should  be  avoided,  regular  exercise  taken,  and  the 
bowels  moved  daily  with  mineral  oil,  which  acts  as  a  lubricant, 
aided,  if  need  be,  by  small  doses  of  cascara  sagrada.     Enemata  and 


836  MANUAL    OF    SURGERY 

drastic  purges  are  contraindicated.  The  parts  should  be  kept 
clean,  bathed  with  cold  water  after  defecation,  and  dried  with  a  soft 
rag.  Ointments  or  suppositories  containing  an  astringent  and,  if 
there  is  much  pain,  opium  and  belladonna  may  be  used.  The  fol- 
lowing is  an  example:  acid  gallic  gr.  x,  ex.  opii  gr.  iv,  ex.  bellad. 
gr.  iv,  ung.  petrolat.  §iv.  apply  night  and  morning.  A  simpler 
remedy  is  aqua  hamamelidis,  applied  with  cotton  once  a  day, 
or  more  often.  Strangulated  piles  should  be  reduced  after  anoint- 
ing them  with  oil  or,  if  this  is  unsuccessful,  removed  by  operation. 
Operation  is  indicated  also  when  there  is  prolapse,  ulceration, 
recurring  hemorrhages,  attacks  of  inflammation,  or  pain  requiring 
the  frequent  use  of  opium.  The  liver  should  always  be  examined 
before  operation,  as  in  some  cases  the  bleeding  is  beneficial  rather  than 
harmful.  A  laxative  should  be  given  forty-eight  hours  before,  and 
an  enema  the  day  before  operation,  thus  preventing  soiling  on  the 
table.  Many  operators  omit  shaving.  The  patient  is  anesthe- 
tized and  put  in  the  lithotomy  position,  the  anus  thoroughly  stretched 
and  one  of  the  operations  described  below  performed. 

Ligation  is  easy,  safe,  and  sure.  The  hemorrhoid  is  picked  up 
with  forceps  and  encircled  with  an  incision  going  through  the  mucous 
membrane;  the  base  is  then  transfixed  with  a  double  silk  ligature, 
which  is  tied  on  each  side,  and  the  mass  cut  away. 

Operation  by  the  clamp  and  cautery  is  favored  by  many  surgeons. 
The  pile  is  caught  with  forceps,  and  a  Smith's  clamp,  the  blades  of 
which,  in  order  to  prevent  burning,  are  covered  with  ivory  on  the 
side  which  rests  against  the  mucous  membrane,  applied  to  the  base 
of  the  pile,  in  the  long  axis  of  the  rectum.  The  pile  is  then  removed 
with  scissors,  and  the  base  seared  with  the  cautery  at  a  dull  red 
heat,  after  which  the  clamp  is  removed. 

Whitehead's  operation  consists  in  removal  of  the  entire  pile 
bearing  areas,  and  is  indicated  when  there  are  masses  of  varicose 
veins  which  occupy  the  whole  of  this  region.  A  circular  incision 
is  made  at  the  junction  of  the  skin  and  mucous  membrane;  the  tube 
of  mucous  membrane  containing  the  varicose  veins  is  then  dissected 
up  and  amputated,  and  the  divided  mucous  membrane  sutured 
to  the  skin.  Stricture  and  incontinence  occasionally  follow  this 
operation. 

Linear  excision  is  the  operation  we  prefer,  since  it  is  as  safe, 
so  far  as  bleeding  is  concerned,  as  ligation,  and  does  not  leave 
strangulated  tissue  to  be  eliminated  later.  The  lower  extremity 
of  the  pile  is  caught  with  forceps  and  drawn  downwards.  The 
artery  supplying  the  pile  is  felt  pulsating  above  its  upper  end. 


RECTUM   AND    ANUS  837 

and  tiefl  with  a  suture-ligature  of  catgut.  The  suture  is  pulled 
upwards,  the  forceps  downwards,  and  the  pile  above  the  forceps 
snipped  off  with  scissors  in  the  axis  of  the  bowel.  The  wound, 
which  bleeds  very  little  if  the  artery  has  been  ligated,  is  closed  by 
continuing  the  suture  down  to  the  forceps,  which  are  removed 
by  cutting  beneath  them,  and  the  edges  of  small  raw  surface  thus 
left  brought  together  with  an  additional  stitch. 

After  any  of  these  operations  the  parts  are  protected  with  a 
sterile  gauze  pad,  and  washed  each  day  with  salt  solution.  The 
patient  takes  a  half  ounce  of  mineral  oil  three  times  a  day,  and,  if 
the  bowels  have  not  moved  by  the  third  or  fourth  day,  several  ounces 
of  the  oil  with  an  ounce  of  glycerin  are  given  by  enema.  It  is  often 
necessary  to  catheterize  the  patient  for  the  first  day  or  two,  owing 
to  reflex  retention  of  urine. 

The  treatment  of  hemorrhoids  by  ignipuncture,  and  by  the  injec- 
tion of  carbolic  acid  or  other  substances,  is  not  recommended. 

Prolapse  of  the  rectum  may  involve  the  mucous  membrane  only 
{incomplete  prolapse,  or  prolapsus  ani)  or  the  entire  rectal  wall 
{complete  prolapse  or  prolapsus  recti).  Complete  prolapse  presents 
itself  in  there  forms. 

1.  The  sigmoid  or  the  upper  rectum  becomes  invaginated 
(intussusception),  but  does  not  protrude  through  the  anus. 

2.  The  intussusceptum,  beginning  at  any  point  in  the  rectum 
or  the  sigmoid,  passes  through  the  anal  canal,  which  acts  as  the 
intussuscipiens,  hence  there  is  a  deep  sulcus  between  the  skin  and 
the  outer  surface  of  the  prolapsed  bowel. 

3.  The  anal  canal  also  is  turned  inside  out,  and  merges  with 
the  surrounding  skin  without  the  intervention  of  a  groove.  This 
form  may  or  may  not  be  the  result  of  the  first  or  the  second  form. 
The  causes  are  relaxation  of  the  tissues,  such  as  is  seen  in  the  de- 
biliated,  and  conditions  which  give  rise  to  repeated  and  violent 
straining  e.g.,  enlarged  prostate,  urethral  stricture,  stone  in  the  blad- 
der, phimosis,  constipation,  diarrhea,  and  various  kinds  of  rectal 
irritation,  especially  worms  and  pol>TDi.  An  incomplete  prolapse 
appears  as  a  reducible,  red  or  purplish  cuft"  of  mucous  membrane. 
In  complete  prolapse  the  mass  may  be  of  large  size,  irreducible,  dry, 
and  sometimes  ulcerated  or  even  strangulated.  If  the  upper  rectum 
or  the  sigmoid  is  extruded,  coils  of  small  intestine  or  the  uterus  or 
ovaries  may  be  found  between  the  ascending  and  the  descending 
layers  of  the  prolapse. 

The  treatment  is  removal  of  the  cause,  and  reduction  of  the  pro- 
lapse by  pressing  the  finger  in  the  orifice  after  the  parts  have  been 


838  MANUAL    OF    SURGERY 

oiled;  reduction  is  maintained  by  strapping  the  buttocks  together 
with  adhesive  plaster,  leaving  an  opening  for  the  passage  of  feces. 
In  children  cure  is  often  thus  obtained,  if  care  is  taken  to  prevent 
constipation.  In  adults  the  parts  may  be  kept  in  place  by  a  T- 
bandage,  and  a  daily  movement  of  the  bowels  secured  while  the 
patient  lies  on  one  side.  An  enema  of  cold  water  containing  an 
astringent,  such  as  tannin  or  fluid  extract  of  hydrastis,  also  is  useful. 
When  these  measures  fail  in  the  incomplete  variety,  longitudinal 
strips  of  mucous  membrane  may  be  excised  and  the  wounds  sutured, 
or  the  same  result  obtained  by  the  use  of  caustics  or  the  cautery. 
In  the  first  form  of  complete  prolapse  the  sigmoid  may  be  fastened 
to  the  abdominal  wall  through  an  incision  in  the  iliac  region  {colopexy) . 
In  the  second  and  the  third  forms,  particularly  when  irreducible, 
the  prolapsed  gut  may  be  amputated,  its  continuity  being  restored 
by  sutures.  Numerous  other  methods  are  described,  operations 
designed  to  narrow  the  anus,  e.g.,  by  a  wire  suture,  injection  of 
paraffin,  excision  of  a  wedge  of  tissue,  are  generally  useless.  Sutur- 
ing the  rectum  to  the  sacrum,  and  the  coccyx  (proctopexy)  through 
a  postanal  incision  is  occasionally  successful.  In  Mosclicowitz's 
operation  the  abdomen  is  opened,  the  rectum  pulled  upwards,  and 
the  cul  de  sac  of  Douglas  obliterated  with  sutures  which  include  the 
pelvic  fascia. 

Ulcer  of  the  rectum  may  be  simple  (due  to  foreign  body,  abrasion 
of  feces,  etc.);  specific,  e.g.,  syphiHtic,  gonorrheal  (these  two 
especially  in  women),  tuberculous,  dysenteric,  or  typhoidal;  or 
malignant.  The  symptoms  are  those  of  rectal  irritation,  with 
constipation  or  diarrhea,  and  the  discharge  of  mucus,  pus,  or  blood. 
The  diagnosis  is  made  by  digital  examination  and  the  speculum. 
The  nature  of  the  ulcer  may  be  ascertained  from  the  history,  the 
local  characteristics,  which  are  much  the  same  here  as  elsewhere, 
from  bacteriologic  and  histologic  studies,  and  from  other  tests  for 
the  diseases  mentioned  above.  The  treatment  in  non-malignant 
cases  is  local  applications  of  silver  nitrate,  20  or  30  to  grains 
the  ounce,  after  cleansing  the  rectum  with  hot  water.  Iodoform 
is  useful,  particularly  in  tuberculous  cases;  appendicostomy  or  tempo- 
rary colostomy  may  be  indicated  if  the  ulcer  is  extensive  and  recal- 
citrant. The  general  health  should  receive  attention,  and  in  specific 
or  syphilitic  cases  appropriate  internal  treatment  administered. 
Tumors  of  the  rectum  are  considered  below. 

Stenosis  or  stricture  of  the  erctum  may  be  caused  by  pelvic 
neoplasms  or  cellulitis,  and  by  the  cicatrization  of  wounds  or  ulcers 
of  the  rectum.     It  may  be  also  congenital  or  due  to  malignant 


RECTUM    AND    ANUS  839 

tumors  in  this  region;  the  hitter  will  be  considered  separately. 
Excluding  carcinoma  most  rectal  strictures  are  syphilitic,  and  these 
are  much  more  frequent  in  women.  The  bowel  is  dilated  above  the 
stricture  and  secondary  fistulas  may  form.  The  symptoms  are  pain, 
discharge  (mucus,  pus,  or  blood),  constipation,  deformity  of  the  stool 
(ribbon  or  pipe-stem),  occasionally  attacks  of  diarrhea,  due  to 
enteritis  from  the  irritation  of  retained  feces,  and  finally  in  some 
cases  complete  obstruction.  The  diagnosis  is  made  with  the  finger, 
the  speculum  and,  after  a  barium  enema,  with  the  X-ray.  The 
treatment  in  the  extrinsic  variety  is  removal  of  the  cause,  e.g.,  a 
pelvic  neoplasm,  in  the  intrinsic  form  gradual  dilatation  with  bougies. 
When  in  the  lower  part  of  the  rectum,  the  stricture  may  be  incised 
posteriorly.  In  suitable  cases  the  fiarrowed  segment  may  be  excised, 
and  the  ends  of  the  bowel  united  by  suture.  In  extensive  and 
intractable  cases  colostomy  may  be  the  only  possible  remedy.  Any 
constitutional  disease,  e.g.,  syphilis  or  tuberculosis,  should  receive 
treatment. 

Tumors  of  the  anus  are  uncommon.  Epithelioma  in  this  region 
presents  its  usual  features,  and  causes  enlargement  of  the  inguinal 
glands.  Cancer  of  the  anus,  however,  is  usually  secondary  to  that  of 
the  rectum.     The  treatment  is  excision,  with  the  inguinal  glands. 

Tumors  of  the  Rectum, — Polypus  recti  is  the  most  common 
benign  tumor,  is  most  frequent  in  children  and  is  an  adenoma  with  a 
long  pedicle.  Often  there  are  several  polypi,  and  sometimes  a 
great  number.  In  adults  cancerization  is  a  possibility.  The 
symptoms  are  rectal  irritation,  the  passage  of  blood  or  mucus,  and 
occasionally  prolapse  or  intussusception.  The  treatment  is  removal, 
after  ligating  the  pedicle.  Papilloma  is  unusual,  but  may  occur 
as  a  cauliflower  mass,  the  chief  symptoms  of  which  are  hemorrhage 
and  rectal  irritability.  The  treatment  is  removal,  with  a  portion 
of  the  environing  mucosa.  A  microscopic  examination  should 
always  be  made  to  exclude  malignant  disease.  Sarcoma  is  rare; 
it  appears  as  a  large  flesjiy  mass,  without  primary  ulceration.  The 
symptoms  are  the  same  as  those  of  cancer,  but  occur  at  an  earlier 
age.  The  treatment  is  extirpation.  Leukemic  tumors,  which 
may  occur  in  leukemia  and  Hodgkin's  disease,  although  exceptional, 
should  be  mentioned  because,  owing  to  ulceration  and  hemorrhage, 
they  may  be  mistaken  for  other  lesions. 

Cancer  of  the  rectum  is  usually  cyhndrical-celled,  and  forms  60 
per  cent,  of  the  carcinomata  of  the  large  bowel.  The  disease  may 
begin  as  an  ulcer,  or  as  a  nodule  beneath  the  mucous  membrane  which 
reaches  a  large  size  before  ulcerating.     In  the  former  instance  the 


840  MANUAL   OF    SURGEEY 

growth  ordinarily  extends  annularly  around  the  rectum,  in  the 
latter  it  increases  equally  in  all  directions.  The  consistency  varies 
with  the  amount  of  fibrous  tissue  present ;  thus  the  mass  may  be  soft, 
f ungating  and  friable,  or  extremely  dense  with  an  ulcerated  surface, 
the  margins  of  which  are  hard  and  everted.  The  softer  varieties  are 
the  more  malignant.  Metastases  may  occur  in  the  lumbar  glands, 
liver,  and  peritoneum,  but  are  comparatively  rare  and  late.  The 
disease  is  most  common  in  and  after  middle  life,  but  it  may  occur 
earlier  and  has  been  seen  even  in  childhood.  The  symptoms  are 
(i)  those  of  ulcer,  i.e.,  pain,  rectal  irritability,  and  the  discharge 
of  pus,  blood,  or  mucus;  (2)  those  of  stricture,  i.e.,  diarrhea,  consti- 
pation, deformed  stools  (ribbon  or  pipe-stem),  and  finally  complete 
obstruction,  which  is  less  frequent  than  one  would  think,  since, 
particularly  in  soft  growths,  the  ulceration  keeps  the  canal  open; 
and  in  the  final  stage  (3)  those  of  carcinomatous  cachexia.  In 
many  cases  the  symptoms  are  slight  or  absent,  until  the  disease  is 
far  advanced.  Of  considerable  significance  is  a  sense  of  fullness 
in  the  rectum,  and  "morning  diarrhea."  The  bowels  move  after 
breakfast,  without,  however,  complete,  satisfaction  and  later  there 
is  another  call  or  perhaps  frequent  calls  to  stool,  a  small  quantity 
of  bloody  mucus  and  gas  being  discharged  with  tenesmus;  this 
gives  no  relief  or  only  temporary  relief.  In  the  later  stages  secondary 
fistulae  into  the  bladder,  vagina,  or  opening  externally  may  form. 
The  diagnosis  is  made  with  the  finger,  the  speculum,  and,  after  a 
barium  injection,  with  the  X-ray.  In  doubtful  cases  a  piece  may 
be  excised  for  microscopic  study.  Death  occurs  in  from  one  to 
five  years,  from  exhaustion,  obstruction,  hemorrhage,  or  peritonitis. 

The  treatment  may  be  palliative  or  radical.  Palliative  treatment 
is  indicated  when  the  growth  cannot  be  removed.  The  rectum  is 
irrigated  daily  with  salt  solution,  opium  given  for  pain,  and  colostomy 
performed  at  an  early  period  and  not  postponed  until  obstructive 
symptoms  supervene,  as  it  diverts  the  fecal  current  and  thus  di- 
minishes pain  and  retards  the  progress  of  the  disease.  Radiotherapy 
also  may  be  used. 

Radical  treatment,  or  excision  of  the  rectum,  is  indicated  when 
the  growth  is  movable  and  metastases  are  not  present.  If  the  sacrum, 
base  of  the  bladder,  or  uterus  is  involved,  operation  is  useless.  The 
mortality  of  complete  excision  of  the  rectum  is  about  25  per  cent., 
and  cure  results  in  about  the  same  proportion.  Surgeons  differ  as  to 
the  necessity  of  a  preliminary  inguinal  colostomy.  We  believe  it 
should  always  be  performed,  because  as  soon  as  the  abdomen  is 
opened  the  upper  limits  of  the  growth  can  be  determined  with 


RECTUM    AND    ANUS  841 

accuracy,  and  the  liver,  the  lymph  glands,  and  the  peritoneum 
explored  for  metastases;  because  as  soon  as  the  bowel  is  opened 
the  obstruction,  if  such  exists,  is  overcome,  and  the  intestinal  tract 
drained  of  toxic  material,  thus  permitting  liberal  feeding  and 
assisting  in  recuperation  of  the  patient  before  the  larger  operation; 
because,  owing  to  subsidence  of  the  inflammation  consequent  upon 
functional  activity,  the  mass  often  diminishes  in  size;  and  because 
the  rectum  can  be  thoroughly  irrigated  before,  and  the  field  of  opera- 
tion kept  clean  and  quiet  after,  the  .tumor  is  excised.  The  chief  ob- 
jections arc  the  additional  risk  involved  in  closing  the  artilicial  anus, 
if  such  be  desirable,  and  the  interference  with  thorough  mobilization 
of  the  rectum  at  the  time  of  excision;  the  latter  objection  loses  its 
force  if  the  sigmoid  is  pulled  well  down  at  the  time  of  the  colostomy, 
or  if,  owing  to  a  short  mesosigmoid,  the  artificial  anus  is  made 
in  the  ascending  or  transverse  colon.  The  following  are  the  routes 
by  which  the  rectum  may  be  excised: 

The  vaginal  route  is  indicated  when  a  small  growth  exists  on  the 
anterior  wall.  The  posterior  wall  of  the  vagina  is  split,  the  growth 
excised,  and  the  vagina  and  rectum  sutured. 

The  anal  route  is  indicated  when  the  growth  is  very  low.  The 
anus  is  dilated,  a  circular  incision  made  through  the  rectal  wall 
above  the  external  sphincter,  the  rectum  pulled  out  through  the 
anus  and  amputated,  and  the  two  ends  sutured.  If  the  anus  is 
involved  it  also  must  be  removed,  the  primary  incision  then  being 
made  around  the  anus  externally. 

The  perineal  route  is  indicated  in  growths  occupying  the  lower 
two  or  three  inches  of  the  rectum,  and  is  much  the  same  as  the  pre- 
ceding, except  that  the  incision  extends  back  to  the  coccyx  and,  if 
necessary,  as  far  forward  as  the  scrotum.  In  some  cases  the  external 
sphincter  may  be  preserved. 

The  sacral  route  (Kraske^s  operation)  is  indicated  in  higher 
growths.  With  the  patient  on  the  right  side,  an  incision  is  made 
from  the  posterior  margin  of  the  anus,  upwards  in  the  middle  line, 
to  the  second  piece  of  the  sacrum.  The  coccyx  is  excised,  the  left 
side  of  the  sacrum  below  the  third  foramen  (the  third  sacral  nerve 
sends  a  branch  to  the  bladder)  removed  with  the  chisel,  and  the 
rectum  extirpated.  If  the  sphincter  is  not  involved,  the  upper 
segment  may  be  sutured  to  the  lower.  When  this  is  impossible, 
the  upper  segment  of  bowel  may  be  sutured  in  the  sacral  wound, 
or  the  end  may  be  closed  by  sutures,  providing,  of  course,  a  prelimi- 
nary colostomy  has  been  made.  In  the  Kraske  operation  the  perito- 
neum is  often  opened,  subsequently  being  sutured,  or  packed  with 


842  MANUAL    OF    SURGERY 

gauze.     There  are  several  modifications  of  this  operation,  involving 
more  extensive  removal  of  bone  or  osteoplastic  resection. 

The  ab  domino -perineal  route  is  indicated  in  cases  in  which  the 
growth  extends  too  high  to  be  removed  by  any  of  the  preceding 
methods.  In  Quenu  '5  operation  the  abdomen  is  opened  in  the  middle 
line,  both  internal  iliac  arteries  tied,  the  sigmoid  divided,  the  upper 
segment  of  the  bowel  brought  out  through  an  incision  in  the  left 
iliac  region,  thus  making  a  permanent  artificial  anus,  and  the  lower 
segment  separated  as  far  down  as  possible.  The  abdominal  wound 
is  then  closed,  and  the  rectum  removed  thrcugh  the  perineum.  In 
Weir's  operation  the  abdomen  is  opened,  the  gut  divided  above  the 
tumor,  the  upper  end  of  the  lower  segment  invaginated  and  pulled 
out  through  the  anus,  and  the  involved  segment  amputated.  The 
lower  end  of  the  upper  segment  is  then  drawn  through  the  anus, 
and  united  to  the  lower  segment  by  sutures  (Maunsell's  method). 


(^HAP!  KR  XXTX 

URINARY  ORGANS 

KIDNEY  AND  URETER 

Congenital  abnormalities  of  the  kidney  include  (a)  absence  or 
atrophy  of  one  organ,  the  other  being  hypertrophied  {single  kidney); 
(h)  fusion  of  the  kdneys  (solitary  kidney),  constituting  a  disc  shaped 
mass  lying  in  the  middle  line,  or  if  the  lower  poles  are  joined,  the 
horseshoe  kidney;  (c)  lobulation,  which  is  normal  in  fetal  life  and  in 
some  animals;  (d)  doubling  of  the  ureter  in  whole  or  in  part;  (e)  stric- 
ture of  the  ureter;  (f)  two  or  more  renal  arteries  for  the  same  organ;  and 
(g)  displacement  of  the  kidney,  which  may  be  freely  movable  and 
supplied  with  a  mesonephron  {congenital  floating  kidney) ,  or  fixed  at 
any  point  as  low  as  the  sacrum  or  the  internal  abdominal  ring  {ectopic 
kidney),  it  probably  being  drawn  to  the  latter  situation  by  the 
descent  of  the  testicle;  (h)  sarcoma,  hydronephrosis,  and  cystic  disease 
also  may  be  congenital. 

Examination  of  the  Kidney.^(i)  To  palpate  the  kidney  one 
hand  is  placed  under  the  loin  and  the  other  in  front  beneath  the  ribs, 
while  the  patient  breathes  deeply.  The  patient  should  be  on  the 
back,  on  the  opposite  side,  or  in  some  cases  standing  up.  The  normal 
kidney  descends  slightly  on  deep  inspiration  but  ordinarily  cannot  be 
palpated.  An  enlarged  ureter  can  sometimes  be  felt  through  the 
rectum,  vagina,  or  abdominal  wall.  (2)  The  chief  value  of  percussion 
is  in  determining  the  relations  of  a  swelling  in  the  loin  to  the  colon; 
the  kidney  is  always  behind  the  colon.  (3)  The  X-rays  may  show 
the  normal  kidney,  enlargements  of  various  sorts,  tuberculous 
foci,  stones,  the  ureter  (after  the  passage  of  an  opaque  catheter), 
or  the  ureter  and  the  renal  pelvis  (after  the  injection  of  an  opaque 
solution — Pyelography,  Fig.  469).  As  food,  fecal  matter,  and  gas 
within  the  intestines  produce  confusing  shadows,  the  diet  should  be 
limited  to  liquids  for  24  hours  and  the  bowels  cleared  by  purgation 
before  the  picture  is  taken.  The  urine  should  be  examined  chem- 
ically, microscopically,  and  in  some  cases  bacteriologically,  and  a 
record  kept  of  the  quantity  secreted.  (5)  Cystoscopy  allows  direct 
inspection  of  the  ureteral  orifices  (see  "Examination  of  the  Bladder") 
and  catheterization  of  the  ureters.  The  latter  permits  the  collection 
of  unmixed  urine  from  each  kidney,  and  is  of  great  value  in  determin- 
ing the  presence  of  both  kidneys,  the  location  of  disease  in  one  or  both 

843 


844 


MANUAL   OF    SURGERY 


organs,  the  patency  of  the  ureter,  the  size  of  the  pelvis,  and  Hke  condi- 
tions. The  technic  is  given  in  the  section  on  "Cystoscopy."  (6) 
The  functional  capacity  of  the  kidneys  is  considered  below.     (7) 


Pig.  469. — Skiagraph  inade  after  injecting  collargol  (lo  per  cent.)  into  the  real 
pelvis  (pyelography),  showing  the  size,  shape,  and  position  of  the  renal  pelvis  and 
ureter.  Thorium  nitrate  (15  per  cent.),  potassium  iodid,  sodium  bromide  (25  per  cent.), 
argyrol.  and  other  substances  opaque  to  the  X-ray  may  be  employed  instead  of  collargol. 
Irregularities  in  the  outline  of  the  pelvis  may  be  seen  in  pyelitis,  tumors,  tuberculosis, 
hydronephrosis,  and  pyonephrosis.  The  position  of  the  shadow  will  aid  in  the  differen- 
tiation of  abdominal  tumors,  in  the  detection  of  solitary,  ectopic,  and  horseshoe  kidney, 
and  in  the  localization  of  renal  calcuU  (calculi  in  the  cortex  will  appear  distinct  from  the 
pelvic  shadow).  Various  forms  of  ureteral  obstruction  and  dilatation  also  can  be  demon- 
strated. Care  must  be  exercised  in  making  the  injection,  which  should  be  discontinued 
if  the  patient  complains  of  pain.  If  too  much  pressure  is  used  the  collargol  may  be 
forced  into  the  parenchyma  01  the  kidney,  or  into  a  ruptured  vein,  thus  causing  collargol 
embolism.     Several  deaths  have  occurred  after  pyelography. 

Exploratory  incision  is  indicated  when  all  other  methods  fail  to  give 
the  desired  information,  but  only  in  cases  in  which  the  symptoms  are 
sufficiently  grave  to  demand  operation. 


URINARY    ORGANS  845 

The  functional  capacity  of  the  kidneys  is  determined  before 
performing  a  >c'ri()us  ()i)irati()n  on  one  or^^an,  and  it  is  important  to 
ascertain  that  the  other  kichiey  is  not  only  present  and  healthy,  but 
also  sufficiently  active  to  preserve  the  patient.  After  collecting  the 
urine  from  each  organ  separately  and  simultaneously,  one  or  more  of 
a  number  of  different  methods  may  be  employed,  but  only  the  few 
that  are  of  actual  service  will  be  mentioned. 

(i)  The  amount  and  composition  of  the  urine  secreted  by  each 
kidney  in  a  given  time  is  determined.  The  normal  output  of  each 
kidney  in  twenty-four  hours  is  500  to  750  cc.  of  urine,  10  to  15  grams 
of  urea,  5  to  6  grams  of  chlorids.  A  decrease  of  one-third  in  these 
quantities  indicates  that  the  kidney  is  incompetent  to  sustain  life. 

(2)  The  pJiloridzin  test  consists  in  the  subcutaneous  administration 
of  5  milligrams  of  phloridzin,  which  is  transformed  into  sugar  by  the 
secreting  cells  of  the  kidney.  If  these  cells  are  normal,  sugar  should 
appear  in  the  urine  in  from  fifteen  to  thirty  minutes,  and  continue 
to  be  excreted  for  four  hours.  Delayed  or  prolonged  elimination 
points  to  renal  insufficiency. 

(3)  Chromocystosco py  consists  in  watching  the  ureteral  orifices  for 
the  excretion  of  blue  urine,  after  the  intramuscular  injection  of 
methylene  blue  (15  minims  of  a  5  per  cent,  solution)  or  indigocarmin 
(4  cc.  of  a  4  per  cent,  solution).  A  simpler  plan  is  to  insert  ureteral 
catheters  and  note  when  the  blue  urine  appears  externally.  Nor- 
mally this  should  occur  in  from  10  to  20  minutes  and  continue  24  to 
48  hours.  If  the  blue  is  late  in  appearing  or  disappearing  the  renal 
parench}Tna  is  diseased.  The  phenolsulphonephthalein  test  is  the 
one  Usually  employed.  Six  milligrams  of  this  agent  are  injected 
intramuscularly.  The  urine  drains  from  the  catheter  into  a  test- 
tube  containing  i  drop  of  a  25  per  cent,  sodium  hydroxid  solution, 
which  becomes  pinkish  when  the  drug  appears  in  the  urine.  As  acid 
urine  shows  only  a  faint  orange  tinge,  it  is  made  decidedly  alkahne  by 
adding  more  sodium  hydroxid  solution,  when  it  turns  to  a  brilliant 
red.  The  urine  excreted  during  the  first  hour  is  collectedseparately 
from  that  excreted  during  the  second  hour;  each  hour's  output  is 
now  diluted  to  i  liter  with  distilled  water,  and  a  small  filtered 
portion  compared,  by  means  of  a  colorimeter,  with  a  standard  con- 
sisting of  3  milligrams  of  phenolsulphonephthalein  and  i  or  2  drops  of 
sodium  hydroxid  solution  (25  per  cent.)  in  i  liter  of  water.  The 
reading  must  be  divided  by  two,  since  the  standard  solution  contains 
only  half  the  amount  injected,  thus  if  the  standard  is  adjusted  to  the 
10  mark,  and  the  colored  urine  reaches  20,  the  excretion  is  50  per 
cent,  of  the  3  milligrams  of  the  standard,  or  25  per  cent,  of  the  6 


846  MANUAL    OF    SURGFEY 

milligrams  injected.  Normally  the  drug  appears  in  the  urine  in  from 
5  to  10  minutes,  50  per  cent,  being  eliminated  during  the  lirst  hour, 
15  to  25  per  cent,  during  the  second  hour.  If  the  drug  is  given 
intravenously  it  appears  in  the  urine  in  from  three  to  live  minutes, 
30  per  cent,  being  excreted  in  the  lirst  15  minutes,  and  from  70  to  80 
per  cent,  in  the  first  hour. 

(4)  Chemical  examination  of  the  blood  promises  to  be  of  decided 
value  in  estimating  the  renal  function.  Normally  the  nonprotein 
nitrogen  content  is  below  30  milligrams  to  the  100  cc.  of  blood,  the 
urea  nitrogen  about  one-half  of  this  amount,  and  the  creatinin 
from  one  to  two  milligrams.  When  the  first  reaches  60  or  70  and 
the  last  2  or  3,  there  is  decided  danger  in  operating,  while  over  100 
milligrams  of  nonprotein  nitrogen  is  rarely  found  in  conditions  other 
than  uremia. 

The  presence  of  two  kidneys  may  be  determined  by  the  cysto- 
scope  (presence  of  two  ureteral  orifices) ,  by  the  segregator,  by  palpa- 
tion externally  (occasionally)  or  through  an  incision,  and  in  some 
instances  by  the  X-ray. 

Hematuria,  or  blood  in  the  urine,  may  be  due  to  local  or  general 
causes.  Among  the  local  causes  are  inflammation,  congestion,  trau- 
matism, embolism,  thrombosis,  calculus,  tumors,  ulceration,  and 
parasites  in  any  portion  of  the  urinary  tract.  The  most  important 
parasite  is  the  Bilharzia  hematobia,  which,  in  portions  of  Africa, 
enters  the  body  with  the  drinking  water  and  later  develops  in  the 
veins  of  the  intestine  or  urinary  apparatus.  The  hemorrhage  is 
caused  by  the  discharge  of  ova  through  the  mucous  membrane. 
Bleeding  may  be  produced  also  by  disease  in  neighboring  structures, 
e.g.,  appendicitis,  pelvic  neoplasms  and  inflammations  and  in  the 
female  bloody  urine  may  be  the  result  of  contamination  with  the 
menstrual  fluid.  Among  the  general  causes  are  bacterial  toxemia, 
e.g.,  from  sepsis,  variola,  measles,  scarlet  fever,  enteric  fever,  yellow 
fever,  malaria,  plague,  and  pneumonia;  certain  blood  diseases,  e.g., 
scurvy,  leukemia,  purpura,  and  hemophilia;  intoxications,  such  as 
jaundice  or  those  due  to  mercury,  lead,  arsenic,  cantharides,  turpen- 
tine, and  quinin;  hysteria;  and  vicarious  menstruation.  When  the 
cause  for  the  bleeding  cannot  be  found  the  condition  is  called  essential 
hematuria  (vide  infra).  The  color  of  the  urine  varies  from  red  to 
black.  It  should  be  recalled  that  senna,  rhubarb,  beet  root,  and 
sorrel  make  the  urine  red ;  and  carbolic  and  salicylic  acids,  brown  or 
black.  Hemoglobinuria  is  characterized  by  the  absence  of  corpuscles. 
It  may  be  due  to  any  of  the  causes  mentioned  above;  to  certain  ner- 
vous affections,  e.g.,  angio-neurotic  edema,  Raynaud's  disease,  or 


URINARY    ORGANS  847 

Henoch's  ]nir]nira;  or  to  hemolysis,  the  result  of  extensive  burns, 
freezing,  large  extravasations  of  blood  (especially  into  the  abdomen), 
transfusion  of  blood,  infusion  of  salt  solution,  paroxysmal  hemo- 
globinuria, or  hemolytic  poisons,  e.g.,  ether,  chloroform,  snake- 
venom,  phosphorus,  carbolic  acid,  carbon  monoxid.  In  rental 
hematuria  the  blood  is  intimately  mixed  with  the  urine,  and  may  con- 
tain blood  casts  of  the  renal  tubules  or  ureter.  By  cystoscopic 
examination  blood  may  be  seen  issuing  from  the  ureter.  In 
ureteral  hemorrhage  bleeding  is  often  slight  and  detectable  only  by 
microscopic  examination.  In  vesical  or  prostatic  hematuria  the  urine 
is  often  alkaline,  contains  clots,  and  most  of  the  blood  is  passed  at 
the  end  of  micturition.  In  urethral  hematuria  blood  drips  from  the 
urethra  independently  of  micturition,  and  the  final  urine  passed  may 
be  quite  clear. 

Pyuria,  or  pus  in  the  urine,  may  be  due  to  inflammation,  or 
rupture  of  an  abscess,  into  any  portion  of  the  urinary  tract.  In 
women  with  leukorrhea  pyuria  should  not  be  diagnosticated  unless 
the  specimen  is  obtained  by  catheter.  In  renal  pyuria  the  urine  is 
usually  acid  and  the  pus  can  be  washed  quickly  from  the  bladder,  in 
vesical  pyuria  the  urine  is  generally  alkaline,  and  it  is  diffi.cult  to  make 
the  washings  clear.  Pus  from  the  prostate  may  be  expressed  into  the 
urethra  by  pressure  through  the  rectum,  and  pus  from  the  urethra 
appears  in  the  first  portion  of  urine  passed.  The  source  may  often 
be  located  with  the  cytoscope  or  the  urethroscope. 

Chyluria  may  be  due  to  obstruction  of  the  thoracic  duct  (tumor 
of  the  duct,  pyloric  carcinoma,  calcified  lymph  glands,  gravid  uterus, 
dilated  right  auricle) ,  but  is  usually  caused  by  filariasis. 

Anuria  is  the  condition  in  which  no  urine  is  passed  and  the  bladder 
is  empty.  It  should  not  be  confused  with  retention  of  urine,  in  which 
the  bladder  is  distended  (see  "Bladder  ") .  Anuria  may  be  obstructive 
or  non-obstructive.  Obstructive  anuria  may  be  caused  by  obstruc- 
tion of  the  ureter  of  the  only  existing  or  only  functionating  kidney, 
or  in  rare  instances  by  obstruction  of  both  ureters  simultaneously. 
The  causes  of  ureteral  obstruction  are  given  under  "Hydronephro- 
sis." In  this  variety  of  anuria  uremia  may  not  supervene  for  a 
number  of  days,  even  though  no  urine  is  passed.  The  treatment  is 
nephrotomy  upon  the  obstructed  side,  in  order  to  allow  the  urine  to 
escape.  The  side  to  be  operated  upon  will  usually  be  indicated  by 
pain,  tenderness,  muscular  rigidity,  and  possibly  by  enlargement  of 
the  kidney.  Removal  of  the  cause  of  obstruction,  unless  very  easy, 
should  be  undertaken  at  a  later  date.  Non-obstructive  anuria 
{suppression  of  urine)  may  be  reflex  or  due  to  degenerative  changes  in 


848  MANUAL    OF    SURGERY 

the  kidneys.  Among  the  reflex  causes  are  operations  on  or  injuries  to 
any  portion  of  the  genitourinary  apparatus,  obstruction  to  one 
ureter  the  other  remaining  free,  hysteria,  and  extensive  burns;  in  this 
group  also  uremia  may  be  postponed  for  some  days.  The  treatment 
is  at  first  medical,  and  later  nephrotomy  upon  one  or  both  kidneys. 
Degenerative  changes  in  the  kidneys  may  be  caused  by  nephritis; 
acute  infectious  diseases,  including  septicemia;  poisons,  such  as  phos- 
phorus, turpentine,  carbolic  acid,  cantharides,  ether,  and  chloroform; 
and  by  lesions  like  tumors,  tuberculosis,  and  cystic  disease  of  both 
kidneys.  In  these  cases  uremia  accompanies  or  precedes  the  anuria. 
The  treatment  is  usually  medical,  although  in  a  few  instances  favor- 
able results  have  followed  nephrotomy. 

For  rupture  of  the  kidney  and  ureter  see  "Contusions  of  the 
Abdomen." 

Wounds  of  the  kidney  give  the  same  symptoms  as  ruptures,  plus 
an  external  wound,  from  which  blood  and  urine  may  escape.  The 
treatment  is  that  of  ruptures. 

Wounds  of  the  ureter  may  be  produced  by  stabs,  bullets,  and 
most  frequently  by  the  surgeon  during  abdominal  operations,  espe- 
cially hysterectomy.  The  result  is  peritonitis,  localized  or  generalized, 
and  if  the  patient  survive,  a  urinary  fistula.  The  immediate  treatment 
of  a  lateral  wound  is  suture;  of  complete  division,  anastomosis. 

Ligation  of  the  ureter,  which  is  sometimes  unintentionally  per- 
formed, particularly  during  gynecological  operations,  causes  atrophy 
of  the  kidney  or,  owing  to  ulceration  of  the  ligature  through  the 
ureteral  walls,  an  abscess,  which  on  breaking  leaves  a  fistula.  If, 
owing  to  anuria  and  pain  in  the  back,  ligation  of  the  ureter  is  sus- 
pected, the  diagnosis  may  be  confirmed  by  the  ureteral  catheter, 
and  the  ligature  removed,  or  the  crushed  segment  resected 
and  one  of  the  operations  described  under  ''Ureteral  Anastomosis" 
performed. 

Ureteral  fistulae,  in  addition  to  ruptures,  wounds,  and  ligation, 
may  be  caused  by  sloughing  following  labor,  or  ulceration  the  result 
of  conditions  like  tuberculosis,  carcinoma,  and  calculus.  The 
fistula  may  open  into  one  of  the  hollow  viscera,  the  vagina,  or  on  the 
skin.  The  diagnosis  from  vesical  fistula  can  be  made  by  injecting 
colored  fluid  into  the  bladder  and  by  cystoscopy.  The  first  step 
in  treatment  should  be  the  passage  of  a  catheter  along  the  ureter,  from 
the  bladder,  in  order  to  determine  whether  the  defect  is  lateral 
or  complete  and  to  make  sure  the  canal  below  the  fistula  is  pervious. 
If  the  defect  is  lateral  and  no  obstruction  exists  spontaneous  healing 
may  occur.     Cutaneous  fistulae  in  which   sppotaneous  closure  is 


URINARY    ORGANS  849 

unlikely  shoukl  be  treated  by  some  form  of  ureteral  anastomosis 
(q.v.);  vaginal  listulx-  as  described  under  "Vagina." 

Movable  kidney,  or  nephroptosis,  is  to  be  distinguished  from 
floating  kidney;  in  the  latter  condition,  which  is  said  to  be  always 
congenital,  the  kidney  passes  forward  into  the  abdominal  cavity  and 
is  completely  surrounded  by  peritoneum,  being  attached  to  the  pos- 
terior abdominal  wall  by  a  mesonephron.  In  movable  kidney  the 
organ  is  excessively  mobile  behind  the  peritoneum.  Eighty  per 
cent,  occur  in  women,  and  the  right  kidney  is  involved  in  about  the 
same  proportion.  It  is  most  common  between  twenty  and  forty, 
,  but  may  be  seen  at  any  time  of  life.  The  adrenal  gland  remains 
in  place,  since  it  lies  in  a  separate  compartment  of  the  perirenal 
fascia.  The  causes  are  conditions  which  render  the  abdominal  walls 
flaccid,  such  as  pregnancy,  emaciation,  and  the  removal  of  abdominal 
tumors;  Glenard's  disease;  tight  lacing;  trauma;  and  conditions  which 
increase  the  size  or  weight  of  the  kidney.  In  many  cases  no  cause 
can  be  found,  beyond  the  fact  that  the  patient  has  a  long  and  slender 
waist,  and  this  bodily  conformation  is  inherited,  hence  movable 
kidney  may  exist  in  several  members  of  the  same  family. 

According  to  the  symptoms  the  cases  may  be  divided  into  four 
classes,  (i)  In  most  cases  symptoms  are  absent.  (2)  In  others 
there  is  dragging  pain  in  the  loin,  with  indigestion  and  nervousness. 
(3)  In  this  class  complications  arise.  If  the  ureter  becomes  kinked  or 
twisted,  there  is  transient  hydronephrosis,  with  violent  pain  in  the 
kidney  and  epigastrium,  vomiting,  collapse,  and  subsequently 
elevation  of  temperature  and  the  discharge  of  a  large  quantity  of 
urine  (Dietl's  crisis) ;  if  the  pedicle  becomes  twisted  gangrene  of  the 
kidney  may  ensue.  Dragging  on  the  duodenum  or  bile  ducts  may 
cause  gastric  and  biliary  disturbances  and  even  jaundice,  and  the 
conditicn  is  not  infrequently  as-^ociated  with  chronic  appendicitis  or 
mucous  colitis.  Albuminuria,  pyuria,  and  occasionally  hematuria 
may  octur,  from  congestion  of  the  kidney  or  pyelitis.  (4)  In  this 
group  the  prolapse  is  secondary  to  tuberculosis,  tumor,  hydro- 
nephrosis, or  some  similar  malady,  hence  presents  the  same  symp- 
toms as  the  primary  trouble.  In  all  cases  the  symptoms  are  inten- 
sified by  exercise  or  by  lying  on  the  sound  side,  and  are  usually 
•reheved  by  lying  on  the  back.  The  diagnosis  is  made  by  feeling  the 
kidney  descend  below  its  normal  level  on  deep  inspiration.  In  the 
severe  forms  the  hands  can  be  approximated  above  the  kidney,  and 
in  the  worse  cases  the  kidney  may  be  found  in  the  pelvis;  percussion 
over  the  loin  is  said  to  give  resonance,  but  the  sign  is  fallacious. 
The  X-ray  may  show  the  position  of  the  kidney  and  reveal  unsus- 
pected conditions,  e.g.,  a  calculus. 


850  MANUAL    OF    SURGERY 

Xo  treatment  is  required  in  class  i ;  above  all  the  patient  should 
not  be  told  that  the  kidney  is  movable.  The  treatment  in  class  2  is 
the  application  of  a  straight  front  corset,  adjusted  while  the  patient 
is  lying  down,  forced  feeding,  tonics,  and  rest;  in  class  3,  nephropexy 
in  class  4.  that  of  the  cause. 

Essential  hematuria  (renal  hcmo philia)  is  a  condition  in  which 
there  is  constant  or  intermittent  bleeding  from  one  kidney,  which  on 
exploration  appears  to  be  normal.  Even  microscopic  examination 
of  sections  removed  at  operation  may  reveal  nothing  pathologic, 
although  in  some  instances  the  tissue  shows  the  changes  of  a  diffuse 
interstitial  nephritis.  There  may  be  pain  in  the  loin  and  sometimes, 
owing  to  the  passage  of  clots  down  the  ureter,  renal  colic.  Cysto- 
scopic  examination  shows  blood  isfuing  from  the  ureter  on  the 
aft'ected  side.  The  kidney  should  be  explored  for  diagnostic  pur- 
poses. If  a  lesion  is  found,  the  hematuria  ceases  to  be  ''essential," 
and  the  treatment  is  that  of  the  cause;  if  no  lesion  is  found  the  kidney 
may  be  decapsulated,  but  in  many  instances,  especially  if  a  large 
amount  of  blood  has  been  lost,  nephrectomy  is  the  better  procedure. 

Hydronephrosis,  or  uronephrosis,  is  distention  of  the  pelvis  and 
calices  with  urine,  as  the  result  of  gradual  or  intermittent  obstruction 
of  one  of  the  passages  below.  Sudden  and  complete  obstruction  to  a 
ureter  results  in  cessation  of  the  urinary  secretion  as  soon  as  the  back 
pressure  is  sufficiently  high,  and  after  a  time  in  renal  atrophy;  if, 
however,  the  obstruction  is  removed  within  a  few  wrecks  restoration 
of  the  function  of  the  kidney  may  follow.  The  causes  are  congenital 
and  acquired.  Congenital  hydronephrosis  is  due  to  atresia  of  some 
portion  of  the  urinary  passages;  acquired  hydronephrosis  to  obstruc- 
tion of  the  ureter  by  calculus,  blood  clot,  parasites,  plugs  of  mucus  or 
pus,  or  stricture;  by  tumors,  abscesses,  cysts,  pregnant  uterus,  or 
other  forms  of  external  pressure;  by  valve  formation  at  the  junction 
of  the  pelvis  and  ureter  owing  to  oblique  insertion;  by  kinking,  e.g., 
over  an  accessory  renal  artery  or  from  excessive  mobility  of  the  kid- 
ney and  less  commonly  to  obstructions  in  the  urethra.  In  the  last 
instance  the  hydronephrosis  may  be  double.  As  the  result  of  the 
accumulation  of  urine  in  the  pelvis  of  the  kidney  the  cortex  becomes 
thin  and  in  the  linal  stages  disappears,  the  kidney  being  converted 
into  a  large,  thin  walled,  irregular  cyst.  At  this  time  the  fluid  may 
not  contain  urea  or  other  urinary  solids.  Infection  and  consequent 
pyonephrosis  may  occur  at  any  time.. 

The  symptoms  are  combined  with  those  of  the  causative  lesion. 
Distention  of  the  kidney  gives  rise  to  pain  and  a  tumor  in  the  loin, 
which  fluctuates,  is  dull  on  percussion,  lies  behind  the  colon,  and  may 


URINARY    ORGANS  85I 

disappear  with  the  ])assagc  of  a  hirge  amount  of  urine.  Alternating 
ischuria  and  polyuria  is  known  as  the  jlush-lank  symptom.  The 
cystoscopc  will  show  absence  of  urine  on  the  afTected  side,  and  the 
ureteral  catheter  may  reveal  the  obstruction.  If  the  catheter  passes 
the  obstruction  the  size  of  the  pelvis  may  be  determined  by  mea.^uring 
the  quantity  of  water  (colored  with  methylene  blue  or  collargol, 
2  per  cent.)  which  can  be  injected  before  it  escapes  from  the  ureter 
alongside  of  the  catheter  (normal  pelvis  holds  from  5  to  30  cc), 
or  by  taking  a  pyelogram  (Fig.  469).  Calculi  also  may  be  detected 
with  the  X-ray.  Death  occurs  from  uremia,  sepsis,  pressure  on 
important  organs,  or  rupture  into  the  peritoneal  cavity. 

The  treatment  is  removal  of  the  cause  if  possible,  and  preservation 
of  the  kidney.  Aspiration  is  not  recommended.  If  the  kidney  is 
totally  destroyed,  or  if  the  obstruction  cannot  be  removed,  or  if  a 
permanent  sinus  follows  a  previous  nephrotomy,  nephrectomy  should 
be  performed,  provided  the  other  kidney  is  sufficiently  active  to 
maintain  life. 

Pyelitis,  or  inflamrhation  of  the  pelvis  of  the  kidney,  is  caused  by 
the  colon  bacillus  in  75  per  cent,  of  the  cases,  either  alone  or  mixed 
with  other  pyogenic  organisms,  the  most  frequent  of  which  are  the 
streptococcus  and  the  staphylococcus.  The  bacteria  reach  the  renal 
pelvis  by  one  of  five  routes  (i)  ascending  infection  travels  up  the 
ureter  by  continuity,  or  by  means  of  regurgitated  urine  {urogenous) . 
It  is  the  result  of  obstruction  or  inflammation  in  the  lower  urinary 
passages  (ureter,  bladder,  urethra).  (2)  Hematogenous  infection 
occurs  in  acute  fevers,  such  as  the  exanthemata,  typhoid,  diphtheria, 
pyemia;  and  possibly  in  those  cases  depending  primarily  upon 
localized  forms  of  irritation,  e.g.,  calculus,  parasites,  (the  chief  of 
which  is  the  Bilharzia  hematobia),  tuberculosis,  tumor,  contusion, 
and  the  excretion  of  drugs  like  turpentine  and  cantharides.  It  may 
be  stated  that  ordinarily  bacteria  excreted  by  the  kidneys  produce  no 
evil  effects,  unless  there  is  some  local  irritation  or  some  obstruction 
to  the  free  discharge  of  urine.  Pressure  of  the  gravid  uterus  on  the 
ureter  may  thus  contribute  to  the  etiology  of  the  pyelitis  of  preg- 
nancy. (3)  Lymphatic  injection  accounts  for  the  frequency  of  the 
colon  bacillus;  the  lymph  vessels  from  the  ascending  and  descending 
colon  pass  over  the  renal  capsule  of  the  corresponding  side,  and 
communicate  with  the  lymph  vessels  of  the  kidney.  It  may  be 
possible  also  for  bacteria  to  travel  from  the  bladder  along  the  lym- 
phatics of  the  ureter.  (4)  Direct  injection  is  the  consequence  of 
wounds  or  fistulae.  (5)  Injection  by  contiguity  is  due  to  inflammation 
extending  from  the  surrounding  structures. 


852  MANUAL    OF    SURGERY 

The  symptoms  are  pain  and  tenderness  in  the  kidney,  frequent 
micturition,  intermittent  pyuria,  and  fever  during  the  absence  of  the 
pus  from  the  urine,  which  is  acid  unless  there  is  a  coexisting  cystitis 
with  decomposition  of  the  urine.  Owing  to  the  obstruction  to  the 
urinary  flow  caused  by  swelKng  of  the  mucous  membrane  or  other 
lesion,  a  pyonephrosis  may  develop  and  extension  to  the  kidney  occur 
{pyelonephritis) ;  suppuration  may  extend  also  to  the  surrounding 
tissues. 

The  treatment  is  hot  fomentations,  alkaline  waters,  diuretics, 
urinary  antiseptics,  and.  to  decrease  the  number  of  colon  bacilli  in  the 
large  bowel,  laxatives.  The  external  genitals,  especially  in  infants, 
must  be  kept  clean;  circumcision  should  be  performed  if  there  is 
phimosis;  and,  in  order  to  lessen  the  pressure  on  the  ureters,  pregnant 
women  may  assume  the  knee-chest  position  several  times  daily,  and, 
when  sleeping,  lie  on  the  side  instead  of  on  the  back.  Autogenous 
vaccins  are  of  doubtful  value.  Lavage  with  a  weak  solution  of  one  of 
the  silver  salts,  introduced  through  a  ureteral  catheter,  is  beneficial 
in  some  cases.  If  the  condition  be  caused  by  an  ascending  infection, 
the  bladder  should  receive  appropriate  treatment.  Other  causes  if 
evident  should  be  removed.  If  no  cause  can  be  ascertained  and  the 
symptoms  persist,  the  kidney  should  be  explored,  since  in  many  cases 
the  distinction  between  pyelitis,  pyelonephritis,  and  other  septic 
conditions  of  the  kidney  cannot  be  made  with  certainty. 

Pyelonephritis  is  pyogenic  inflammation  of  the  pelvis  of  the  kid- 
ney and  of  the  renal  parenchjona,  and  is  due  to  the  same  causes  as 
pyeHtis.  The  symptoms  are  chills,  fever,  pain  and  tenderness  in  the 
kidney,  vomiting,  headache,  and  later  signs  of  exhaustion  and  uremia. 
The  urine  is  small  in  amount,  usually  contains  pus,  and  sometimes 
blood.  The  treatment  is  that  of  pyeHtis.  If  both  kidneys  are 
afifected  the  prognosis  is  extremely  grave. 

Pyonephrosis,  or  distention  of  the  pelvis  of  the  kidney  with  pus,  is 
the  result  of  infection  of  a  hydronephrosis,  or  retention  of  pus  in 
pyelitis.  The  cortex  is  invaded  and  the  kidney  finally  represented 
by  a  large  multilocular  pus  sac  (Fig.  470),  surrounded  by  adhesions, 
through  which  the  pus  may  break  establishing  a  fistulous  communi- 
cation with  the  bowel  or  the  skin,  or  setting  up  a  fatal  peri- 
tonitis. The  symptoms  are  those  of  hydronephrosis,  plus  those  of 
sepsis.  The  quantity  of  pus  in  the  urine  depends  upon  the  degree  of 
obstruction.  It  may  be  intermittent  or  entirely  absent.  Death 
occurs  from  sepsis  or  uremia.  The  treatment  in  unilateral  cases  is 
nephrotomy,  removal  of  the  cause  if  possible,  and  drainage,  or  if  the 
kidney  is  hopelessly  disorganized,  nephrectomy.     If  both  organs  are 


URINARY    ORGANS  853 

involved  treatment  is  usually  hopeless,  although  double  nephrotomy 
may  be  employed  in  suitable  cases. 

Abscess  of  the  kidney  is  due  to  the  same  causes  as  pyelitis. 
Pyemic  abscesses  are  always  small  and  multiple,  and  generally 
bilateral,  hence  not  amenable  to  treatment.  Chronic  abscesses  are 
usually  tuberculous.  The  symptoms  of  an  acute  solitary  abscess 
are  pain,  tenderness,  and  muscular  rigidity  on  the  affected  side,  and 
the  constitutional  symptoms  of  sepsis.  The  abscess  cannot  be 
detected  by  palpation  unless  it  is  of  large  size.  Pyuria  may  be 
present  or  absent.  The  treatment  is  nephrotomy  and  drainage,  or,  if 
the  whole  kidney  is  destroyed,  nephrectomy. 

Acute  unilateral  hematogenous  infection  of  the  kidney  is  due 
to  pyogenic  cocci  which  have  been  brought  from  a  distance,  e.g.,  from 
the  tonsil  or  a  furuncle.  The  kidney  is  swollen,  and  studded  with 
minute  reddish  areas,  which  suppurate.  Several  of  these  abscesses 
may  then  coalesce,  and  the  process  extend  to  the  pelvis.  The  symp- 
toms are  sudden  severe  pain  in  the  back  and  sometimes  in  the  abdo- 
men; tenderness,  which  is  most  marked  in  the  costovertebral  angle; 
muscular  rigidity;  and  general  evidences  of  sepsis,  frequently  ter- 
minating in  dehrium,  coma,  and  death.  The  urine  on  the  affected 
side,  as  determined  by  cystoscopy  and  ureteral  catheterization,  may 
be  scanty  and  contain  pus  and  blood,  but  if  the  pelvis  is  not  involved 
the  urine  may  be  clear.  The  condition  is  not  infrequently  confused 
wuth  intraabdominal  affections,  especially  when  right  sided,  with 
appendicitis.     The  treatment  is  nephrectomy. 

Perinephritis,  or  inflammation  of  the  perinephritic  fat,  may  be 
caused  by  trauma,  infection  from  the  blood,  and  extension  from 
environing  parts  (spine,  pleura,  ribs,  liver,  intestine),  but  is  usually 
secondary  to  suppurative  processes  in  the  kidney.  The  symptoms 
are  pain,  tenderness,  muscular  rigidity,  and  if  suppuration  occurs, 
fever,  and  the  presence  of  a  mass  in  the  loin.  A  perinephritic  ab- 
scess usually  points  alongside  of  the  erector  spinae,  but  may  descend 
into  the  iHac  fossa  or  burst  into  the  pleura,  peritoneum,  or  intestine. 
The  treatment  of  perinephritis  in  the  absence  of  suppuration  is  hot 
fomentations,  sedatives,  and  attention  to  the  general  health;  a  peri- 
nephritic abscess  should  be  opened  and  drained.  In  all  cases  the 
cause  should,  if  possible,  be  determined  and  removed. 

Spontaneous  perirenal  hematoma  is  due  to  the  rupture  of  one  of 
the  blood  vessels  of  the  renal  capsule,  or,  more  rarely,  to  the  rupture 
of  a  vessel  in  the  neighborhood  of  the  kidney.  The  blood  collects 
beneath  the  capsule,  or  breaks  through  the  capsule  and  infiltrates 
the  retroperitoneal  tissues,  sometimes  extending  as  far  as  the  dia- 


854  MANUAL    OF    SURGERY 

phragm  and  the  scrotum.  In  most  cases  the  kidney  is  chronically 
inflamed  and  the  arteries  sclerotic.  The  symptoms  in  a  severe  case 
are  those  of  internal  hemorrhage,  with  sudden  violent  pain  and  a 
rapidly  developing  tumor  in  the  region  of  the  kidney.  Blood  is 
often  not  found  in  the  urine. 

The  treatment  is  nephrectomy,  or,  in  mild  cases,  evacuation  of  the 
hematoma  and  tamponage.  Of  i6  cases  operated  upon  recovery 
followed  in  ii,  of  seven  not  operated  upon  death  ensued  in  all 
(Lippens) . 

Ureteritis,  or  inflammation  of  the  ureter,  is  practically  always 
secondary  to  pyelitis  or  cystitis.  Primary  ureteritis  is  possible,  e.g., 
from  calculus  or  injury,  but  is  very  rare.  In  the  acute  variety  there 
is  a  pyogenic  inflammation  of  the  mucosa.  Clironic  ureteritis 
presents  itself  in  two  forms,  (i)  In  the  dilated  form  the  ureter  is 
dilated  and  tortuous  from  obstruction,  the  muscular  coat  under- 
going h}-pertrophy  and  the  mucosa  cystic  changes.  (2)  In  the 
fibroid  form  the  ureter  is  straight,  thickened,  shortened,  densely 
adherent,  and  strictured  in  numerous  places. 

The  symptoms  are  usually  masked  by  the  causative  pyelitis  or 
cystitis.  Occasionally  tenderness  can  be  elicited  through  the  ab- 
dominal wall,  and  the  thickened  ureter  can  often  be  felt  through  the 
vagina  and  sometimes  through  the  rectum.  The  ureteral  orifice, 
as  seen  with  the  cytoscope,  is  dilated  or  contracted,  retracted  or 
pouting,  and  almost  always  rigid  (noncontracting)  and  reddened. 
Strictures  are  revealed  by  the  ureteral  catheter.  The  treatment  is 
that  of  the  cause. 

Tuberculosis  of  the  kidney  may  be  ascending  or  descending. 
In  the  former,  which  is  more  frequent  in  men,  the  original  focus  is 
often  in  the  prostate  or  epididymis,  from  which  the  infection  spreads 
to  the  bladder,  thence  ascends  the  ureter  and  invades  the  pelvis  and 
finally  the  parenchyma,  hence  both  organs  are  generally  affected. 
In  the  descending  type,  which  represents  about  two-thirds  of  the 
cases,  and  which  is  more  common  in  women  (3  to  i),  the  bacilh  are 
deposited  from  the  blood  and  the  disease  is  called  primary,  i.e.,  it  is 
primary  so  far  as  the  urinary  organs  are  concerned,  but  generally 
secondary  to  a  lesion  in  some  other  portion  of  the  body,  notably  the 
lungs.  This  t>^e  is  usually  unilateral,  commences  in  the  paren- 
chyma, extends  to  the  pelvis  and  ureter,  and  in  about  half  the  cases  to 
the  bladder  and  the  other  kidney.  The  changes  are  those  of  tubercu- 
losis elsewhere.  Caseation  occurs  and  the  abscesses  open  into  the 
pehis  or  exceptionally  through  the  capsule.  In  the  later  stages  the 
kidney  is  densely  adherent  from  perinephritis,  thus  rendering  neph- 


URINARY   ORGANS  855 

rectomy  difficult  and  dangerous.  The  symptoms  are  frequent  mic- 
turition with  dysuria,  slight  pain,  or  from  transient  blocking  of  the 
ureter  severe  colic,  pyuria,  occasionally  hematuria,  and  in  the  later 
stages  chills,  fever,  and  sweats,  due  to  secondary  infection  with 
pyogenic  organisms.  The  kidney  is  tender  and  enlarged,  but  one 
should  not  rely  on  this  sign  alone,  as  the  larger  organ,  even  though 
tender,  may  be  the  healthy  one,  greatly  hypertrophied  because  it  is 
doing  the  work  of  both.  Nodules  may  be  detected  in  the  prostate, 
epididymis,  vas,  or  seminal  vesicle.  Tubercle  bacilli  are  sometimes 
found  in  the  urine.  If  they  are  not  found  the  urine  may  be  inocu- 
lated into  a  guinea  pig.  A  sterile  pyuria,  in  itself,  is  highly  suggestive 
of  tuberculosis.  The  cytoscope  reveals  a  dilated,  rigid  (noncon- 
tracting),  and,  owing  to  the  thickening  and  shortening  of  the  ureter, 
retracted  ureteral  orifice,  which  is  often  surrounded  by  ulcers  or 
tubercles  (Fig.  473).  The  thickened  ureter  can  be  felt  through  the 
vagina  and  sometimes  through  the  rectum  or  abdominal  wall.  The 
X-ray  may  show  the  tuberculous  focus,  which,  owing  to  calcareous 
infiltration,  sometimes  casts  a  dense  shadow  closely  resembling  that 
of  a  calculus.  The  prognosis  is  favorable  if  all  of  the  disease  can  be 
removed;  decidedly  unfavorable  in  all  other  cases,  death  occurring 
usually  from  uremia,  sepsis,  or  generalized  tuberculosis.  Circum- 
scribed tuberculosis  of  the  bladder  due  to  infection  from  the  kidney 
may,  however,  subside  after  ureteronephrectomy.  The  treatment  is 
medical  if  both  kidneys  are  involved.  Perinephritic  abscesses  should 
of  course  be  incised.  If  the  disease  is  unilateral  the  kidney  should  be 
explored.  If  the  focus  is  strictly  limited,  a  partial  nephrectomy  ^^dth 
subsequent  suture  of  the  wound  may  be  tried,  but  in  most  instances 
the  disease  will  be  found  so  extensive  that  the  entire  organ,  with  the 
ureter,  will  require  removal. 

Renal  calculi  {nephrolithiasis)  are  formed  by  the  precipitation  of 
urinary  salts,  which  are  then  bound  together  by  an  albuminoid 
substance  derived  from  the  mucous  membrane  as  the  result  of  a 
preexisting  inflammation  or  as  the  result  of  the  irritation  induced 
by  the  deposited  salts. 

The  causes  are  general  and  local.  The  most  important  general 
cause  is  faulty  metabohsm  from  overeating,  improper  diet  (excess  of 
nitrogenous  food,  sugar,  and  acids,  too  little  w^ater) ,  alcohol,  indiges- 
tion neurasthenia,  lack  of  exercise,  and  debilitating  diseases  character- 
ized by  anemia  and  wasting.  According  to  the  substance  which 
appears  in  excess  in  the  urine  the  condition  is  called  the  uric  acid 
diathesis  (lithemia),  oxaluria,  phosphaturia,  etc.  Lithemia  and  the 
tendency  to  the  formation  of  uric  acid  stones  may  be  inherited. 


856  MANUi^L    OF    SURGERY 

Renal  calculi  occur  at  all  ages,  are  more  frequent  in  males,  and  are 
bilateral  in  30  per  cent,  of  the  cases.  The  endemic  nature  of  nephro- 
lithiasis in  certain  districts  has  been  attributed  to  the  presence  of 
large  quantities  of  lime  in  the  drinking  water,  or,  owing  to  a  warmer 
climate,  to  the  increased  density  of  the  urine  as  the  result  of  excessive 
perspiration.  In  India,  Egypt,  China,  and  other  tropical  countries, 
where  stone  is  very  prevalent,  the  Bilharzia  hematobia  orthefilaria 
sanguinis  hominis  is  held  responsible,  the  ova  of  the  former  or  the 
embryos  of  the  latter  forming  the  nuclei  for  the  stones.  The  chief 
local  causes  are  infection  of  the  kidney  or  its  pelvis  and  obstruction 
to  the  outflow  of  urine.  Here  must  be  mentioned  also  the  possi- 
bility of  a  nucleus,  which  may  be  composed  of  epithelium,  bacteria, 
blood  clot,  pus  cells,  a  foreign  body,  or,  as  mentioned  above,  animal 
parasites. 

The  appearance  of  a  renal  stone  varies  with  its  composition, 
which,  it  must  be  noted,  is  not  always  the  same  throughout.  Stones 
usually  consist  of  uric  acid  or  urates,  sometimes  of  oxalate  or  phos- 
phate of  lime,  and  very  rarely  of  carbonates,  cystin,  or  xanthin. 
Uric  acid  calcuH  are  oval,  smooth,  brownish,  very  dense,  usually 
laminated,  frequently  multiple,  and  sometimes  of  large  size.  Those 
composed  of  urates  are  lighter  in  color,  less  dense,  and  not  so  dis- 
tinctly laminated.  The  oxalate  of  lime  calculus  is  round  or  oval, 
very  heavy  and  hard,  distinctly  laminated,  dark  brown  or  black  in 
color,  and  spiculated  or  nodular,  hence  the  name  mulberry  calculus; 
it  develops  very  slowly,  is  seldom  of  large  size,  and  is  usually  single. 
Phosphatic  calculi  are  composed  of  triple  phosphates,  are  whitish, 
soft,  friable,  usually  fetid  and  rarely  laminated.  They  form  when 
the  urine  becomes  alkaline  from  retention  and  decomposition  or 
from  the  drinking  of  alkaline  waters,  and  may  attain  a  large  size. 
Any  stone  or  foreign  body  may  have  a  phosphatic  coating.  Car- 
bonate of  Hme  calculi  are  round,  hard,  and  white;  cystin  calculi 
small,  soft,  smooth,  friable,  and  waxy  in  appearance;  xanthin  calculi 
reddish-brown  in  color,  small,  and  hard.  Renal  calcuH  are  multiple 
in  two-thirds  of  the  cases,  in  which  event  they  are  often  faceted. 
They  vary  in  size  from  fine  granules  (gravel)  to  a  mass  almost  as 
large  as  the  kidney  itself  (Fig.  470).  Stones  in  the  parenchyma  are 
usually  rounded;  in  the  pelvis  often  pyramidal,  dendritic,  or  coral- 
like, in  some  cases  forming  a  cast  of  the  pelvis;  in  the  ureter  oval. 

The  symptoms  vary  with  the  situation  of  the  calculus.  If  it  is 
situated  in  the  parenchyma  (20  per  cent,  of  renal  stones)  and  is 
smooth  there  may  be  no  symptoms.  As  a  rule,  however,  there  is 
pain  in  the  loin,  which  is  increased  by  jolting,  and  which  may  be 


URINARY    ORGANS 


857 


felt  also  in  the  groin,  thigh,  testicle  (sometimes  with  retraction  of 
this  organ),  and  occasionally  along  the  back  of  the  lower  limb  as 
far  as  the  heel.  In  rare  instances  it  is  referred  to  the  other  kidney. 
There  may  be  no  urinary  changes.  Tenderness  on  pressure  can 
almost  always  be  elicited.  Abscess  of  the  kidney  may  follow. 
When  the  stone  lies  in  the  pelvis  of  the  kidney  (80  per  cent,  of 
renal  stones)  it  usually  causes  pyehtis  (pyuria,  hematuria,  frequent 
micturition,  etc.).  If  the  stone  passes  douii  the  ureter  symptoms  of 
renal  colic  follow,  viz.,  sudden,  excruciating,  paroxysmal  pain, 
passing  from  the  loin  along  the 
ureter  to  the  testicle,  which  is  re- 
tracted; vomiting;  collapse; 
strangury;  and  hematuria,  which 
is  often  detectable  only  by  the 
microscope.  The  pain  ceases  if 
the  calculus  slips  back  into  the 
pelvis,  or  if  it  reaches  the  bladder. 
The  stone  may  lodge  near  the 
pelvis  of  the  kidney,  close  to  the 
bladder,  or  at  the  brim  of  the  bony 
pelvis,  the  point  of  impaction  being 
excessively  tender.  Sudden  and 
complete  obstruction  is  followed 
by  suppression  of  urine  on  the 
corresponding  side  and  atrophy  of 
the  kidney,  or  by  death  if  the  other 
kidney  is  not  functionally  active. 
Occasionally  the  other  kidney,  even 
when  healthy,  suddenly  ceases  to 
secrete  urine  {reflex  anuria) .  In- 
complete or  intermittent  obstruc- 
tion causes  hydronephrosis  or 
pyonephrosis.  In  some  cases  the 
stone  ulcerates  through  the  wall  of  the  ureter  into  the  abdomen 
or  retroperitoneal  tissues.  Having  passed  through  the  ureter  the 
stone  may  remain  in  the  bladder  as  a  vesical  calculus,  be  passed 
with  the  urine,  or,  particularly  in  male  children,  become  impacted 
in  the  urethra.  A  calculus  in  the  lower  portion  of  the  ureter  may 
occasionally  be  palpated  through  the  vagina  or  rectum.  The 
cystoscope  may  show  edema  of,  or  a  stone  in,  the  ureteral  meatus, 
a  dilated  meatus,  a  difference  in  the  urine  on  the  two  sides,  or  absence 
of  the  urine  on  the  affected  side.     As  a  catheter  sometimes  passes 


Fig.  470. — Skiagram  shown.     Fig.  471. 
Calculous  pyonephrosis. 


858  MANUAL    OF    SURGERY 

a  stone,  Kelly  suggests  the  use  of  a  wax-tipped  ureteral  bougie, 
upon  which  scratches  will  be  made  if  a  calculus  is  present.  The 
X-rays  (Fig.  471)  detect  the  stones  in  90  per  cent,  of  the  cases. 
They  may  fail  to  show  very  small  stones,  pure  uric  acid  stones,  and 
stones  hidden  beneath  the  twelfth  rib.  Failure  in  the  last  instance 
may  be  avoided  by  taking  two  plates  at  different  angles.  They 
may  apparently  show  a  stone  when  none  exists,  the  source  of  error  being 
a  defective  plate,  or  shadows  cast  by  phleboliths,  atheromatous 
plates,  appendical  concretions,  gall  stone,  tuberculous  foci,  calcified 
lymph  glands,  centers  of  ossification  in  the  pelvic  ligaments,   der- 


FiG.   471. — Skiagram  of  multiple  renal  calculi.      Specimen  shown  Fig.  470. 

moids,  foreign  bodies,  and  fecal  masses  (hence  the  necessity  of 
preliminary  purgation).  The  shadows  of  ureteral  calculi  are  gener- 
ally oval ,  with  the  long  axis  in  the  line  of  the  ureter.  That  the  shadow 
is  cast  by  a  stone  in  the  ureter  (Fig.  472)  can  be  proved  by  passing 
an  X-ray  (leaded)  catheter  into  the  ureter  and  taking  stereoscopic 
plates,  or  by  making  a  ureterogram,  i.e.,  a  skiagram  of  the  ureter 
filled  with  an  opaque  solution.  Braasch  determines  the  exact  site 
of  a  renal  stone  by  means  of  the  pyelogram.  If  the  stone  is  in  the 
renal  pelvis,  it  may  show  through  the  pyelogram,  if  in  a  calyx,  on 
the  edge  of  the  pyelogram;  and  if  in  the  parenchyma,  separate 
from  the  pyelogram.     As  calculi  are  present  in  both  the  kidneys 


URINARY    ORGANS 


859 


iind  tlu'  ureter  in  5  per  cent,  of  the  cases,  and  are  bilateral  in  30 
per  cent,  of  the  cases  the  skiagram  should  always  include  both 
kidnevs  and  both  ureters. 


Fig.  472. — -Skiagram  of  a  ureteral  calculus  impacted  near  the  bladder.  An  X-ray 
catheter  was  passed  into  each  ureter;  oh  the  affected  side  the  catheter  met  with  obstruc- 
tion three-fourths  of  an  inch  from  the  ureteral  orifice;  on  the  opposite  side  the  catheter 
passed  up  the  ureter  without  difficulty.  The  stone,  which  was  removed  e.xtraperi- 
toneally,  through  an  incision  above  and  parallel  with  Poupart's  ligament,  is  shown, 
actual  size,  in  the  right  lower  corner  of  the  illustration. 

The  diagnosis  is  often  missed  because  of  atypical  symptoms, 
thus  of  607  patients  with  nephrolithiasis  (combined  statistics  of 
Cabot  and  Braasch)  169,  or  almost  28  per  cent.,  had  had  an  un- 
necessary abdominal  operation  performed.  The  cases  in  which 
confusion  is  hkely  to  occur  are  (a)  those  in  which  renal  calcuh  are 


86o  MANUAL    OF    SURGERY 

mistaken  for  other  conditions,  and  (b)  those  in  which  other  conditions 
are  taken  for  renal  calcuh.  (a)  Gastrointestinal  symptoms  in 
nephrolithiasis  may  arise  from  pylorospasm,  uremia,  or,  when  there 
is  renal  cohc,  from  intestinal  paralysis;  the  gall-bladder,  the  pylorus, 
the  duodenum,  the  colon,  and  the  kidney  are  in  close  proximity, 
and  the  appendix  may  overlie  the  ureter;  hence  the  principal  con- 
ditions which  renal  or  ureteral  calculi  may  simulate  are  gall-stones, 
gastric  or  duodenal  ulcer,  colitis,  intestinal  obstruction,  and  most 
frequently  appendicitis.  Persistent  albuminuria,  without  casts 
or  other  evidences  of  nephritis,  should  always  suggest  the  possibility 
of  stone,  (b)  The  principal  conditions  which  may  simulate  renal 
or  ureteral  calculi  are  diseases  of  the  kidney  and  ureter  other  than 
those  produced  by  stones,  vesiculitis,  testicular  lesions,  incipient 
inguinal  hernia  with  neuralgia  of  the  spermatic  cord,  appendicits 
with  hematuria,  the  crises  of  locomotor  ataxia,  and  spondylitis; 
all  of  these,  except  spondylitis,  may  give  genitourinary  symptoms. 
Of  the  greatest  importance  in  the  differential  diagnosis  of  nephro- 
lithiasis are  (i)  the  character  of  the  pain  in  relation  to  the  other 
symptoms,  it  often  being  very  severe  without  muscular  rigidity, 
fever,  or  leukocytosis,  unless  there  are  septic  compHcations;  (2) 
costovertebral  tenderness,  which,  owing  to  distension  of  the  renal 
pelvis,  is  frequently  present  even  in  ureteral  stone;  (3)  the  absence 
of  muscular  rigidity,  although  rigidity  is  possible,  especially  in  the 
presence  of  inflammation,  but  is  then  lumbar  as  well  as  lateral, 
and  more  lumbar  than  lateral;  (4)  hematuria,  which  may  be  revealed 
only  by  the  microscope,  and  which  is  present  in  80  per  cent,  of  the 
cases;  (5)  the  cystoscope;  and  (6)  the  X-ray.  The  diagnosis  can 
be  made  with  certainty  in  90  per  cent,  of  the  cases,  if  one  only 
suspects  the  condition  and  has  a  skiagram  made;  and  it  can  be  made 
in  more  than  90  per  cent,  of  the  cases,  if  one  employs  the  cysto- 
scope and  the  ureteral  catheter. 

The  treatment,  if  the  stone  is  small,  quiescent,  and  in  the 
parenchyma,  may  be  directed  to  the  lithemia,  in  order  to  prevent 
augmentation  of  the  stone  or  the  formation  of  others;  this  consists 
in  exercise,  regulation  of  the  diet,  attention  to  the  bowels,  plenty 
of  water,  alkaline  diuretics,  and  piperazin.  Under  even  these 
circumstances,  however,  the  possibihty  of  evil  effects  is  by  no  means 
small,  and  unless  there  are  serious  contraindications  nephrohthotomy 
is  probably  the  safer  course,  an  operation  which  becomes  imperative 
if  symptoms  or  complications  arise.  A  stone  in  the  pelvis  practically 
always  causes  trouble,  and,  unless  minute  enough  to  pass  down  the 
ureter,   should  be  removed  by  pyelohthotomy.     A  stone  moving 


URINARY    ORGANS  86l 

down  the  ureter  causes  renal  colic,  which  requires  hot  fomentations, 
hot  drinks,  and  the  hypodermatic  administration  of  atropin  and 
morphin.  If  impaction  with  complete  obstruction  occurs  immediate 
operation  is  demanded  to  save  the  kidney,  or  if  there  is  anuria  to  save 
life.  In  impaction  with  incomplete  obstruction  large  quantities 
of  water  by  mouth  and  injections  of  sweet  oil  into  the  ureter  through 
a  catheter  may  be  tried.  A  calculus  projecting  into  the  bladder 
may  be  dislodged  with  forceps  introduced  through  the  operating 
cystoscope;  if  the  calculus  is  just  above  the  ureteral  meatus,  the 
meatus  is  sometimes  dilated,  occasionally  split.  If  these  measures 
fail  to  dislodge  the  stone  it  should  be  removed  by  one  of  the  forms  of 
ureterolithotomy  or,  in  some  cases,  when  situated  near  the  kidney, 
by  pyelotomy  after  it  has  been  pushed  back  into  the  pelvis. 
Nephrectomy  is  indicated  only  when  the  kidney  is  totally  destroyed 
and  the  other  organ  is  healthy.  Recurrence  of  the  stones  after 
operation  occurs  in  9.8  per  cent,  of  the  cases.  Naturally  some  of 
the  so-called  recurrences  are  due  to  stones  that  have  been  over- 
looked at  the  time  of  operation. 

Tumors  of  the  kidney  are  relatively  infrequent,  and  include 
cancer,  sarcoma,  and  hypernephroma,  the  last  forming  80  per  cent, 
of  the  cases.  Sarcoma  is  most  often  seen  in  childhood,  hyper- 
nephroma in  and  after  middle  life.  Angioma,  papilloma,  adenoma, 
and  rarely  other  benign  tumors  also  have  been  observed.  The 
symptoms  are  pain,  hematuria,  and  the  presence  of  a  growth  in  the 
loin,  the  tumor  lying  behind  the  colon,  moving  slightly  with  respira- 
tion, and  having  the  shape  of  the  kidney.  The  differential  diagnosis 
between  renal  tumor  and  an  enlarged  gall-bladder  is  given  under 
"Hydrops  of  the  Gall-bladder."  Hematuria  occurs  in  75  per  cent, 
of  the  cases,  and  is  often  profuse,  intermittent,  and  painless.  In  one 
of  our  cases  the  diseased  kidney,  probably  owdng  to  its  vascularity, 
secreted  more  urine  than  its  fellow.  In  malignant  cases  acute 
varicocele  may  occur  from  the  pressure  of  enlarged  glands  on  the  root 
of  the  spermatic  vein,  and  cachexia  sooner  or  later  develops.  Pig- 
mentation of  the  skin  indicates  invasion  of  the  suprarenal  body. 
Sarcoma,  including  hypernephroma,  may  give  rise  to  metastases  in 
the  lungs,  liver,  and  bones,  indeed  secondary  growths  in  the  last 
situation  may  be  the  first  sign  of  trouble.  Papilloma  of  the  renal 
pelvis  is  very  likely  to  become  malignant;  it  may  cause  death  from 
hemorrhage,  and  occasionally  some  of  the  villous  tufts  become 
detached  and  appear  in  the  urine.  In  renal  tumor  the  pyelogram 
may  show  an  indentation  or  other  irregularity  in  the  outline  of  the- 
pelvis.     The  treatment  is  nephrectomy,  unless  the  growth  is  benign 


862  MANUAL    OF    SURGERY 

and  small,  when  it  alone  should  be  removed.  Recurrence  after 
operation  for  malignant  disease  of  the  kidney  takes  place  in  90  per 
cent,  of  the  cases. 

Cysts  result  from  interstitial  nephritis  (small  and  not  treated 
surgically),  from  obstruction  to  one  of  the  ducts,  or  from  hydatid 
disease.  Dermoid  cysts  also  have  been  observed.  When  of  large 
size  they  may  be  detected  by  palpation.  In  hydatid  disease  the 
hooklets  may  sometimes  be  found  in  the  urine.  The  treatment  is 
enucleation,  or  in  the  worst  cases  nephrectomy.  Congenital  cystic 
disease  of  the  kidney  is  characterized  by  large  multilocular  cysts, 
probably  the  result  of  defective  development  of  the  Wolffian  body. 
The  symptoms  are  the  presence  of  a  tumor,  and  occasionally  pain, 
albuminuria,  and  hematuria.  As  both  kidneys  are  involved  in  98 
per  cent,  of  the  cases,  surgical  treatment  is,  as  a  rule,  contraindicated ; 
one  may  be  forced  to  operate,  however,  for  complications,  viz., 
suppuration,  severe  hematuria,  hydronephrosis,  anuria,  intestinal 
obstruction,  painful  crises  due  to  displacement.  When  one  organ 
alone  is  involved,  it  may  be  excised;  if  both  organs  are  affected  the 
operation  must  be  conservative,  i.e.,  nephrotomy,  nephropexy,  or 
decapsulation  with  excision  or  puncture  of  the  cysts. 

OPERATIONS  ON  THE  KIDNEY  AND  URETER 

The  kidney  may  be  exposed  through  the  abdomen  or  through  the 
loin.  The  abdominal  route  is  selected  if  a  very  large  tumor  is  to  be 
attacked.  The  incision  is  made  through  the  semilunar  line,  the 
peritoneal  cavity  opened,  and  the  organ  exposed  by  an  incision 
through  the  posterior  parietal  peritoneum  at  the  outer  side  of  the 
colon.  The  lumbar  route  is  chosen  whenever  possible.  The  patient 
should  be  placed  upon  the  sound  side  with  the  thighs  and  knees 
flexed  and  a  sand  bag  or  air  cushion  under  the  loin,  in  order  to  widen 
the  costoiliac  space  and  push  the  kidney  up  into  the  wound.  The 
incision  may  be  vertical  or  oblique.  The  vertical  incision  runs  close 
to  the  outer  border  of  the  erector  spinae,  from  one-half  inch  below  the 
last  rib  to  the  crest  of  the  ilium.  The  fibers  of  the  latissimus  dorsi  are 
separated,  the  lumbar  fascia  incised,  and  the  quadra tus  lumborum 
and  the  erector  spinae  retracted  inwards.  The  last  thoracic,  the 
iliohypogastric,  and  the  ilioguinal  nerves  lie  beneath  the  quadratus 
and  should  be  drawn  aside,  or,  if  severed,  sutured  at  the  end  of  the 
operation.  The  kidney  is  exposed  by  tearing  through  the  perirenal 
fat.  If  more  room  is  needed,  the  incision  may  be  extended  outwards 
in  a  transverse  direction  above  the  crest  of  the  ilium.     The  oblique 


URINARY    ORGANS  863 

incision  extends  from  the  outer  l)or(ler  of  the  erector  spina^,  one-half 
inch  below  the  twelfth  rib,  downwards  and  outwards  towards  the 
anterior  s]nne  of  the  ilium.  The  latissimus  dorsi,  external  oblique, 
internal  obliciue,  and  the  transversalis  muscle  and  fascia  are  divided. 

Nephropexy  has  been  performed  in  many  different  ways,  but  only 
the  most  important  can  be  mentioned.  Edehohls  delivers  the  kidney 
through  the  wound,  excises  the  fatty  capsule,  makes  an  incision 
through  the  fibrous  capsule  along  the  convex  border  of  the  kidney, 
turns  the  capsule  half  way  back  towards  the  pelvis,  passes  two  mat- 
tress sutures  through  the  reflected  capsule  on  each  side  of  the  kidney, 
and  replaces  the  kidney.  The  sutures  are  not  tied  until  they  have 
been  passed  from  within  outwards  through  the  muscles.  The  wound 
is  then  closed.  It  has  been  suggested  also  to  tunnel  under  the 
fibrous  capsule,  and  thread  the  tunnel  on  the  twelfth  rib ;  to  throw  a 
free  transplant  of  fascia  lata  around  the  kidney  and  suture  the 
sling  to  the  fascia  of  the  back.  The  passage  of  sutures  through  the 
parenchyma  is  undesirable.  Da  Costa  passes  a  strip  of  gauze,  com- 
posed of  two  pieces  sutured  together  with  catgut,  around  each 
pole  of  the  kidney,  and  ties  the  strips  over  additional  gauze  which 
fills  the  wound  superficial  to  the  kidney.  After  the  catgut  is  ab- 
sorbed the  strips  are  easily  removed.  The  gauze  creates  a  bed  of 
cicatricial  tissue  which  holds  the  kidney  in  place. 

Nephrotomy,  or  incision  of  the  kidney,  is  performed  after  deliver- 
ing the  kidney  through  the  wound,  whenever  possible.  The  length 
and  direction  of  the  incision  will  vary  with  the  condition  to  be  treated. 
When  done  for  exploratory  purposes,  the  incision  is  made  along  the 
convex  border,  just  behind  the  mesial  plane,  at  which  place  the  ven- 
tral and  dorsal  vessels  meet  and  the  least  bleeding  occurs.  If  neces- 
sary the  whole  kidney  may  be  split  and  laid  open  like  a  book.  An 
assistant  should  compress  the  renal  vessels  during  this  procedure  in 
order  to  prevent  hemorrhage.  Through  the  incision  the  interior  of 
the  kidney  and  the  pelvis  can  be  explored  and  bougies  passed  down 
the  ureter.  The  wound  may  be  closed  with  mattress  sutures  of 
catgut,  which  necessarily  interrupt  the  vascular  supply  to  portions  of 
the  parenchyma.  If  bleeding  continues  tamponage  with  fat  or 
muscle,  as  described  under  rupture  of  the  kidney,  should  be  con- 
sidered. As  a  rule  the  wound  cannot  be  made  dry,  and  drainage 
must  be  inserted.  We  have  had  several  dangerous  secondary 
hemorrhages  after  nephrotomy,  demanding  removal  of  the  kidney, 
hence  never  perform  it  unless  forced  to  do  so.  Nephrolithotomy 
is  nephrotomy,  plus  the  removal  of  stones  with  the  finger  or  with 
forceps.     The  calculi,  if  not  accurately  localized  by  the  X-ray, 


864  MANUAL    OF    SURGERY 

may  be  found  by  palpation,  or  by  puncturing  the  organ  with  a 
needle.     Drainage  will  usually  be  required. 

Pyelotomy,  or  incision  of  the  pelvis  of  the  kidney,  is  called  pyelo- 
lithotomy  when  done  for  stone.  The  kidney  is  delivered,  the  poste- 
rior wall  of  the  pelvis  opened  transversely  to  avoid  the  vessels,  and 
the  wound  subsequently  sutured  or  drained,  according  to  indica- 
tions. In  pyelohthotomy  one  should  disturb  the  fat  over  the  pos- 
terior wall  of  the  pelvis  no  more  than  is  absolutely  necessary;  it 
reinforces  the  suture  line  and  helps  to  prevent  the  escape  of  urine; 
in  many  cases  thus  treated  urine  never  flows  through  the  wound  in  the 
loin.  The  old  belief  that  urinary  fistula  is  more  apt  to  follow  than 
after  nephrotomy  has  been  proved  untrue. 

Nephrostomy  is  the  making  of  an  opening  into  the  pelvis  of  the 
kidney  through  the  parenchyma  for  the  purpose  of  diverting  the 
urine  from  the  ureter  and  the  bladder.  A  similar  purpose  may  be 
served  by  pyelostomy,  or,  when  the  bladder  alone  is  to  be  put  at  rest, 
by  ureterostomy  or  ureteroenterostomy .  Watson  recommends  double 
nephrostomy,  instead  of  the  other  operations  just  mentioned,  before 
total  cystectomy,  and  in  cases  of  inoperable  tumor  or  tuberculosis  of 
the  bladder.  The  ureter  is  tied  close  to  the  renal  pelvis,  the  kidney 
incised,  and  a  tube  inserted.  After  the  fistula  is  established  the 
urine  is  collected  in  a  specially  constructed  reservoir,  which  is 
strapped  to  the  back. 

Nephrectomy,  or  removal  of  the  kidney,  should  not  be  performed 
until  the  presence  and,  if  possible,  the  functionating  capacity  of  the 
other  kidney  have  been  ascertained.  The  kidney  may  be  removed 
through  the  abdomen  or  by  the  lumbar  route.  The  advantage?  of 
the  abdominal  route  are  that  the  pedicle  can  be  more  easily  controlled 
and  the  other  kidney  palpated ;  the  latter  maneuver  may  be  accom- 
plished also  in  the  lumbar  operation,  after  incising  the  peritoneum  ou 
the  outer  side  of  the  colon.  The  great  objection  is  that  the  perito- 
neum is  opened,  hence  it  is  employed  only  when  the  organ  is  too  large 
to  be  dealt  with  through  the  loin.  In  either  method  the  kidney  is 
shelled  from  its  bed,  and  the  ureter  and  renal  vessels  tied  separately. 
It  should  be  recalled  that  accessory  renal  vessels  exist  in  20  per  cent, 
of  the  cases.  When  the  operation  is  done  for  malignant  disease,  the 
fatty  capsule  also  should  be  removed;  if  for  tuberculosis,  the  ureter, 
when  involved,  likewise  should  be  excised.  Partial  nephrectomy  is 
performed  by  removing  a  wedge-shaped  portion  of  the  kidney  and 
suturing  the  wound. 

Decapsulation  of  the  kidneys  for  chronic  nephritis  consists  in 
exposing  the  kidneys,  peeling  off  the  fibrous  capsules,  and  dropping 


URINARY    ORGANS  865 

the  kidneys  back  into  pkice.     Inijirovement  follows  in  some  cases, 
but  the  exact  value  of  the  operation  has  not  yet  been  determined. 

The  ureter  may  be  palpated  through  an  abdominal  incision, 
as  suggested  by  Gibbon,  but  should  not  be  opened  by  this  route, 
because  of  the  danger  of  peritonitis.  The  upper  ureter  may  be 
exposed  through  the  lumbar  incision  made  for  operations  on  the 
kidney;  the  lower  ureter  by  an  incision  running  from  just  above  the 
anterior  superior  spine  of  the  ilium,  downward  and  forward,  one-half 
inch  above  and  parallel  with  Poupart's  ligament,  to  the  inguinal 
canal;  the  whole  ureter  by  combining  these  incisions.  The  peri- 
toneum is  stripped  trom  the  parietes  until  the  ureter  is  reached. 
In  operating  through  the  lower  incision  the  ureter  is  usually  found  by 
following  the  external  iliac  artery  to  its  origin;  the  ureter  crosses  the 
vessels  at,  or  just  above  or  below,  this  point.  Identification  is 
ordinarily  simple,  because,  in  the  presence  of  disease,  the  ureter  is 
almost  always  dilated  or  thickened,  or  both.  The  lower  end  of  the 
ureter  may  be  attacked  also  through  the  bladder,  vagina, perineum, 
or  by  a  modified  Kraske  operation. 

Ureteropyelostomy,  or  anastomosis  between  the  ureter  and  the 
pelvis  of  the  kidney,  has  been  performed  in  cases  of  hydronephrosis 
due  to  impermeable  stricture  of  the  upper  end  of  the  ureter  or  kinking 
of  the  ureter  over  the  renal  vessels.  The  same  result  has  been  ob- 
tained by  an  operation  similar  to  pyloroplasty,  or  by  excising  the 
valve  which  is  sometimes  found  between  the  hydronephrotic  sac  and 
the  ureter. 

Ureterolithotomy  consists  in  opening  the  ureter  by  a  longitudinal 
incision  and  removing  the  calculus,  after  the  ureter  has  been  exposed 
by  one  of  the  routes  mentioned  above.  If  near  the  bladder  the  stone 
may  sometimes  be  displaced  upwards  to  a  more  favorable  site  for 
attack,  or  the  ureter  may  be  incised  in  an  easily  accessible  region  and 
the  stone  extracted  with  long  slender  forceps.  The  ureteral  wound 
may  be  sutured  with  fine  catgut,  or  drained,  and  allowed  to  close  at 
a  later  period. 

Ureteral  anastomosis  may  be  performed  in  the  same  manner  as 
lateral  anastomosis  of  the  intestine.  In  lateral  implantation  {Van 
Hook's  operation)  the  end  of  the  lower  segment  of  the  ureter  is  ligated, 
and  an  opening  made  below  the  ligature,  into  which  the  lower  end  of 
the  upper  segment  is  drawn  by  a  catgut  suture  which  passes  through 
this  end  and  then  into  the  lateral  opening  and  out  through  the 
ureteral  wall  about  one  quarter  of  an  inch  below  the  opening,  the 
end  of  the  upper  segment  having  been  previously  split  in  a  longitudi- 
nal direction  to  prevent  stenosis.     When  this  operation  is  not  feasi- 


866  MANUAL   OF    SURGERY 

ble,  the  ureter  may  be  anastomosed  to  the  bladder  [ureterocystostomy) , 
to  the  pelvis  of  the  kidney  (ureteropyelostomy) ,  or  even  to  the  intes- 
tine (ureteroenterostomy) ;  the  last  method,  however,  is  very  likely  to 
be  followed  by  peritonitis  or  infection  of  the  kidney.  When  a  great 
length  of  the  ureter  has  been  injured  or  destroyed,  it  may  be  neces- 
sary to  suture  the  ureter  to  the  skin  {ureterostomy)  or  to  remove  the 
corresponding  kidney.  Substitution  of  a  piece  of  vein  for  a  seg- 
ment of  the  ureter  has  been  successfully  accomphshed  in  the  dog. 

THE   BLADDER 

Attention  has  already  been  called  to  congenital  umbilical  -and 
rectal  fistulse  communicating  with  the  bladder. 

Ectopia  vesicae,  or  extroversion  of  the  bladder,  is  a  congenital 
absence  of  the  anterior  wall  of  the  bladder,  the  soft  tissues  which 
should  overlie  it,  and  of  the  symphysis  pubis.  It  is  most  common  in 
males,  the  upper  wall  of  the  urethra  also  being  wanting  [complete 
epispadias).  The  posterior  wall  of  the  bladder  with  the  ureteral 
openings  is  pressed  forwards  and  becomes  inflamed  owing  to  ex- 
posure. The  urine  dribbles  away  constantly  and  the  inflammation 
may  spread  up  the  ureters  to  the  kidneys.  The  treatment  is  very 
unsatisiactory.  The  patient  may  wear  a  urinal  or  be  subjected  to 
operation.  Efforts  may  be  made  to  close  the  bladder  by  suturing 
the  mucous  edges  together,  or  by  utilizing  flaps  from  the  neighboring 
skin  or  a  piece  of  intestine.  To  facilitate  the  approximation  of  a 
large  opening  the  sacroiliac  ligaments  have  been  divided,  and  the 
cleft  in  the  symphysis  pubis  obliterated  by  forcible  compression. 
The  urethra  has  been  patched  with  a  skin  flap.  A  new  urethra, 
opening  within  the  sphincter  ani,  so  as  to  avoid  incontinence,  has 
been  made  from  the  skin  of  the  perineum  and  the  wall  of  the  rectum. 
The  rectum  has  been  severed,  in  order  to  create  a  bladder  from  the 
distal  segment,  the  lower  end  of  the  upper  segment  being  sutured  to 
the  skin  just  behind  the  anus  but  within  the  sphincter  ani.  A  new 
bladder  has  been  made  from  the  cecum,  the  appendix  acting  as  the 
urethra.  In  order  to  prevent  the  urine  from  flowing  over  the  in- 
flamed vesical  mucous  membrane  the  ureters  have  been  implanted  in. 
the  urethra,  vagina,  skin  of  the  abdominal  wall.  The  ureters  have 
been  anastomosed  with  the  intestine  in  various  ways;  probably  the 
best  method  is  that  in  which  the  ureters  with  the  trigone  are  im- 
planted into  the  sigmoid.  The  valvular  openings  of  the  ureters  are 
thus  preserved  and  bacteria  prevented  from  ascending  to  the  kidney; 
urine  collects  in  the  sigmoid  and  is  voided  at  intervals. 


URINARY   ORGANS  867 

For  injuries  of  the  bladder  sec  "  Contusions  of  the  Abdomen." 

Examination  of  the  bladdernuiy  Ix' made  by  palpation  through 
tlic  hypogastrium,  rectum,  or  in  the  female  through  the  vagina  or 
even  the  dilated  urethra.  Percussion  and  inspection  of  the  hypo- 
gastrium also  may  give  information.  The  introduction  of  a  sound 
through  the  urethra  may  detect  a  calculus  or  tumor.  The  X-ray  is  of 
value  chiefly  for  the  detection  of  stones  and  foreign  bodies,  the  size, 
shape,  and  position  of  the  bladder  can  be  demonstrated  after  in- 
jecting air  or  a  solution  opaque  to  the  a;-rays.  Cystoscopy  is  de- 
scribed below.  Since  vesical  symptoms  may  be  of  genital  or  rectal 
origin,  these  organs  should  always  be  investigated  after  the  bladder 
has  been  examined.  Owing  to  the  perfection  of  the  cystoscope 
exploratory  cystotomy  is  rarely  indicated. 

Cystoscopy  is  the  most  important  and,  indeed,  excluding  ex- 
ploratory incision,  sometimes  the  only  method  for  diagnosticating 
endovesical  conditions.  It  permits  inspection  also  of  the  prostate 
and  ureteral  orifices,  the  introduction  of  catheters  into  the  ureters, 
lavage  and  medication  of  these  ducts  and  of  the  renal  pelvis,  topical 
applications  to  the  bladder,  and  the  removal  of  small  intravesical 
growths,  stones,  and  foreign  bodies.  It  cannot  be  used  when  the 
urethra  is  too  small  to  admit  the  instrument,  e.g.,  in  stricture  and 
in  young  children,  and  when  the  bladder  will  not  hold  the  requisite 
amount  of  fluid;  and  it  is  generally  contraindicated  in  acute  injiam- 
matory  troubles  of  the  urethra,  bladder,  and  prostate;  in  tuberculosis 
of  the  bladder,  unless  the  diagnosis  cannot  be  made  by  other  means; 
and,  because  of  the  danger  of  suppression  of  urine,  in  acute  nephritis. 
Boys  over  10  and  girls  over  6  years  can  be  cystoscoped  with  an  in- 
strument whose  caliber  is  16  or  18  F. 

The  cystoscope  consists  of  a  hollow  shaft,  shaped  like  a  stone 
sound,  with  an  electric  light  at  the  end,  and  one  or  more  telescopes 
which  slide  into  the  shaft.  The  lens  system  in  the  telescope  is  so 
arranged  as  to  enable  the  examiner  to  see  that  part  of  the  bladder 
toward  which  the  instrument  is  directed  (direct  system),  or  the  part  at 
right  angles  to  the  instrument  (indirect  system) .  In  some  cystoscopes 
both  systems  may  be  used  with  the  same  shaft,  which  also  contains 
channels  for  the  passage  of  ureteral  catheters,  operating  instruments, 
and  channels  for  irrigating  the  bladder.  When  the  indirect  system[is 
used  for  catheterizing  the  ureters,  the  catheter  is  directed  towards  the 
ureteral  orifice  by  a  lever  on  the  end  of  the  cystoscope,  which  is  raised 
or  lowered  by  a  screw  on  the  external  end.  A  special  cystoscope  may  be 
employed  for  endovesical  operations.  The  male  cystoscope  answers 
equally  well  in  the  female.     The  cystoscope  and  ureteral  catheters 


868  MANUAL    OF    SURGERY 

may  be  sterilized  by  immersion  in  a  solution  of  formalin  (2  per  cent.) 
for  thirty  minutes,  after  which  all  traces  of  the  antiseptic  should  be 
removed  with  sterile  water.  For  ordinary  examinations  anesthesia 
is  not  required ;  if  the  urethra  is  sensitive,  however,  about  4  drams  of 
a  10  per  cent,  solution  of  procain  may  be  instilled  into  the  urethra 
and  bladder  portion  by  a  urethral  syringe  or  a  catheter;  occasionally 
in  nervous  patients  a  general  anesthetic  must  be  employed.  The 
buttocks  are  elevated  and  brought  over  the  end  of  the  table,  the 
thighs  being  separated  and  slightly  flexed,  the  feet  resting  on  chairs; 
a  special  table  is  convenient  but  not  essential.  The  external  genitals 
are  disinfected  and  washed  with  sterile  water.  The  light  is  then 
turned  on  for  a  moment  to  test  the  lamp;  the  instrument  lubricated 
with  glyoerin  or  liquid  vaselin  and  passed  into  the  bladder  like  a 
sound;  the  bladder  irrigated  with  cool  sterile  water  until  it  is  clean, 
adding,  however,  adrenalin  chlorid  in  the  proportion  of  i  to  10,000, 
if  there  is  bleeding;  at  least  5  ounces  of  the  fluid,  but  preferably 
10  or  12,  allowed  to  remain  in  the  bladder,  so  as  to  distend  it  and 
prevent  burning;  the  telescope  slipped  into  the  sheath;  and  the  light 
turned  on.  If  the  fluid  quickly  becomes  turbid  the  examination  may 
be  made  under  continuous  irrigation. 

If  catheterization  of  the  ureters  is  desired  the  instrument  is  brought 
to  the  middle  line  and  slowly  withdrawn  until  the  interureteral  bar 
(which  forms  the  posterior  boundary  of  the  trigone)  comes  into 
view;  this  is  followed  laterally  until  the  slit-like  ureteral  meatus 
appears  (Fig.  474),  which  is  usually  on  the  summit  of  a  Httle  teat, 
and  may  be  identified  by  noting  that  at  intervals,  generally  varying 
from  30  to  60  seconds  or  more,  it  opens  like  a  fish  mouth,  ejects  a 
swirl  of  urine,  and  closes  again.  The  catheter  is  protruded  from  the 
instrument,  gently  pressed  against  the  orifice,  and  then  passed  up  the 
ureter  (Fig.  476).  The  procedure  is  next  repeated  on  the  opposite 
side,  the  light  turned  off,  the  fluid  allowed  to  escape  from  the  bladder, 
and  the  catheters  fed  through  the  cystoscope  as  it  is  withdrawn,  so 
as  not  to  pull  them  from  the  ureters.  Each  catheter  is  passed  into 
a  test  tube,  which  is  plugged  with  cotton,  and  fastened  by  means 
of  adhesive  plaster  to  the  corresponding  thigh.  It  is  a  good  plan 
to  use  a  catheter  of  different  color  for  each  side  so  that  no  confusion 
as  to  which  is  which  can  arise.  As  a  rule,  even  with  the  gentlest 
manipulation,  some  blood  will  be  found  in  the  samples,  hence  it  is 
advisable  to  collect  the  urine  from  each  side  in  two  or  three  tubes, 
allowing  each  to  remain  in  position  one-half  hour  or  longer,  accord- 
ing to  the  amount  of  urine  excreted.  If  a  catheter  does  not  drain, 
gentle  suction  with  a  syringe  should  be  tried;  failing  this  not  more 


URINARY    ORGANS 


869 


than  2  diiid  drams  of  sterile  water  may  be  injected.  The  functional 
capacity  of  the  kidney?,  pyelography,  and  chromocystoscopy  are 
considered  under  "Examination  of  the  Kidney;"  the  means  of 
measuring  the  pelvis,  under  "Hydronephrosis;"  the  use  of  opaque 
catheters,  under  "Renal  Calculi." 

Incontinence  of  urine  is  the  involuntary  escape  of  urine,     (i)  In 
true  or  passive  inconlinence  the  urine  flows  out  of  the  bladder  as  soon 


Fig.  473. 


Fig.  474. 


Fig.  475.  Fig.  476. 

Pigs.  473  to  476.— Cystoscopic  pictures. 
Fig.  473  .—Dilated,  rigid  (noncontracting) ,  retracted  ureteral  meatus,  surrounded  by- 
ulcers  and  tubercles,  characteristic  of  renal  tuberculosis.     Fig.  474. — Normal  ureteral 
meatus.     Fig.  475. — Jet  of  pus  coming  from    ureter.     Fig.  476. — Catheter  entering 
ureter. 


as  it  flows  in,  and  the  bladder  is  never  distended.  It  is  seen  in 
conditions  like  ectopia  vesicae,  fistulae  leading  into  the  bladder, 
paralysis  of  the  bladder,  and  paralysis  of  the  sphincter  vesicae  the 
result  of  disease  or  injury  of  the  vesical  sphincter  or  of  its  center  in 
the  spinal  cord;  it  occurs  also  from  propping  open  of  the  internal 
meatus  by  a  growth  or  calculus.  (2)  Active  incontinence  is  due  to 
exaggeration  of  the  vesical  reflex.     It  is  most  common  in  children, 


Syo  MANUAL   OF   SURGERY 

occurring,  as  a  rule,  only  during  sleep.  It  may  be  symptomatic,  i.e., 
due  to  phimosis,  stone,  highly  acid  urine,  seat  worms,  spinal  disease, 
rectal  disorders,  or  constipation,  but  in  most  cases  it  is  idiopathic, 
i.e.,  no  cause  can  be  found,  except  perhaps  that  the  child  is  neurotic. 
These  cases  are  treated  by  removing  any  existing  irritation,  admin- 
istering belladonna  and  tonics,  waking  the  child  at  night  to  pass 
water,  and  by  sending  the  patient  to  bed  thirsty.  Imperative 
urination,  coming  on  every  few  minutes,  and  due  to  inflammation 
or  other  form  of  irritation,  is  sometimes  called  false  incontinence. 
(3)  The  incontinence  of  retention  (paradoxical  ischuria)  is  the  over- 
flow of  a  distended  bladder,  due  to  some  obstruction,  such  as  stric- 
ture or  enlarged  prostate,  or  to  paralysis  of  the  detrusor,  such  as 
may  occur  in  spinal  diseases  and  injuries. 

Retention  of  urine  is  distention  of  the  bladder  owing  to  inability 
to  pass  urine.  The  causes  of  retention  are:  i.  Obstruction,  such  as 
phimosis;  hgature  about  the  penis;  tumor  or  abscess  of  the  perineum; 
stricture,  calculus,  foreign  body,  rupture,  tumor,  abscess,  or  con- 
genital occlusion  of  the  urethra,  inflammation,  abscess,  tumor, 
hypertrophy,  or  calculus  of  the  prostate;  and  external  pressure,  such 
as  fecal  impaction  and  uterine  tumors.  2.  Non-obstructive  lesions, 
such  as  atony  or  paralysis  of  the  bladder,  reflex  inhibition  (e.g.,  after 
injuries  of  or  operations  on  the  rectum),  hysteria,  fevers,  shock,  and 
drugs  like  belladonna,  opium,  and  cantharides.  The  most  common 
cause  in  the  new  born  is  occlusion  of  the  urethra,  in  infants  phimosis, 
in  children  impacted  calculus,  in  youth  one  of  the  complications  of 
gonorrhea  (male)  or  hysteria  or  foreign  body  in  the  bladder  (female) , 
in  men  stricture,  in  women  pelvic  disease,  and  in  old  age  prostatic 
hypertrophy.  In  acute  obstructive  retention  the  bladder  wall  is 
greatly  thinned;  in  chronic  obstructive  retention,  usually  greatly 
thickened  (excentric  hypertrophy),  and  often  trabeculated,  the  tra- 
becalae  representing  hypertrophied  muscular  fasciculi,  which  cross 
in  a  net-like  manner,  thus  forming  deep  sacculations  in  the  mucous 
coat.  Trabeculation  from  increased  work  may  be  due  also  to  vesical 
irritation,  e.g.,  from  chronic  cystitis,  calculi,  tumors,  tuberculosis, 
or  foreign  bodies;  in  these  cases,  if  there  is  no  obstruction,  the 
bladder  is  contracted  (concentric  hypertrophy). 

The  symptoms  in  obstructive  cases  are  pain,  intense  desire  but 
inability  to  urinate,  and  frequent  straining  eft'orts.  The  bladder 
may  be  seen  and  felt  above  the  pubes  as  a  median,  symmetrical, 
pyriform,  fluctuating  tumor,  which  is  dull  on  percussion,  and 
pressure  upon  which  increases  the  desire  to  urinate.  It  may  be 
palpated  also  through  the  rectum  or  vagina.     The  obstruction  is 


URINARY    ORGANS  871 

encountered  on  attcmi)tin<i;  to  pass  a  catheter.  The  distention 
increases  until  some  urine  is  forced  through  the  obstruction,  or  until 
the  back  pressure  induces  suppression  of  urine.  The  bladder  does 
not  burst  unless  injured  or  ulcerated,  although  the  posterior  urethra 
may  give  way  if  the  obstruction  is  lower  down.  In  non-obstructive 
retention  the  patient  may  make  no  complaint,  and  as  the  urine 
begins  to  dribble  away  when  the  bladder  can  hold  no  more,  the 
condition  may  be  mistaken  for  incontinence.  Retention  is  to  be 
distinguished  also  from  suppression,  as  in  each  no  urine  is  voided. 
In  the  former  the  signs  of  a  distended  bladder  are  in  evidence,  and 
the  introduction  of  a  catheter  is  impossible,  or  results  in  the  with- 
drawal of  a  large  quantity  of  urine.  In  the  latter  the  bladder  is 
empty  and  no  urine  is  obtained  by  the  catheter. 

The  treatment  ot  non-obstructive  retention  following  operations 
is  given  under  "Surgical  Technic"  (Chap.  IV),  and  what  is  said 
there  applies  to  most  of  the  other  forms  of  non-obstructive  retention. 
The  details  of  the  treatment  of  obstructive  retention  vary  with  its 
cause.  If  it  is  not  possible  to  remove  the  obstacle  to  urination  at 
once,  and  a  catheter  cannot  be  passed  into  the  bladder,  the  patient 
must  be  relieved  by  suprapubic  or  perineal  cystotomy,  or  by  para- 
centesis vesicce,  i.e.,  the  plunging  of  a  fine  trocar  into  the  bladder, 
in  the  middle  line  immediately  above  the  pubes. 

Atony  of  the  bladder  (loss  of  tone  of  the  muscular  walls)  is 
physiological  in  old  age.  The  pathological  causes  are  acute  or 
chronic  retention,  and  lesions  involving  the  nervous  mechanism 
of  the  bladder,  e.g.,  injury  of  the  spinal  cord  or  of  the  motor  nerves 
of  the  bladder,  Pott's  disease,  spina  bifida,  and  diseases  of  the  spinal 
cord,  especially  syphilis,  including  locomotor  ataxia.  If  the  nervous 
impulses  are  completely  interrupted  paralysis  of  the  bladder  and 
true  incontinence  ensue.  The  symptoms  of  atony  are  difficulty  in 
starting  micturition,  lessened  force  of  the  stream,  and  dribbling  at 
the  completion  of  the  act.  There  is  always  some  residual  urine, 
which  is  apt  to  decompose  and  set  up  a  cystitis.  The  treatment 
is  that  of  the  cause  (obstructive  or  nervous),  and  catheterization 
to  draw  off  the  residual  urine.  The  catheter  is  to  be  used  once  per 
day  for  every  two  ounces  of  residual  urine,  thus  if  there  are  eight 
ounces  of  residual  urine,  the  catheter  should  be  used  every  six  hours. 
Urinary  antiseptics,  strychnin,  and  electricity  also  may  be  employed. 

Cystitis,  or  inflammation  of  the  bladder,  may  be  acute  or  chronic. 
The  morbid  anatomy  and  the  varieties  are  the  same  as  those  of 
inflammation  in  other  mucous  membranes.  The  three  important 
factors  in  the  production  of  cystitis  are   (a)   infection,   (b)   local 


872  MANUAL   OF   SURGERY 

irritation,  and  (c)  obstruction.  A. — Injection  reaches  the  bladder 
by  one  of  six  routes,  i . — Direct  infection  is  the  result  of  a  wound,  or 
the  passage  of  nonsterile  instruments  into  the  bladder.  An  aseptic 
catheter  may  cause  cystitis  by  pushing  bacteria  from  the  urethra 
into  the  bladder,  or,  in  the  presence  of  bacteriuria,  by  injuring  the 
vesical  walls.  2. — Descending  infection  comes  from  the  kidney, 
e.g.,  in  acute  fevers  and  in  tuberculosis.  3.- — Ascending  infection 
travels  up  from  the  urethra,  e.g.,  in  gonorrhea,  or  through  the 
urethra  from  the  epididymis,  seminal  vesicle,  or  prostate.  4. — In- 
fection by  contiguity  extends  from  neighboring  structures,  e.g., 
from  the  rectum,  female  pelvic  organs,  or  from  an  appendix  lying 
against  the  bladder.  Little  stress  is  laid  on  (5)  hematogenous 
infection,  since  cystitis  is  rarely  a  primary  afifection.  6. — ^Lympho- 
genous infection  also  is  mentioned  merely  as  a  possibihty.  As 
with  the  kidney,  bacteria  may  be  present  in  the  urine  without 
inducing  inflammation  of  the  bladder,  so  long  as  there  is  no  local 
irritation  or  obstruction.  Even  pus  may  flow  through  the  bladder, 
on  its  way  from  the  kidneys,  without  causing  cystitis.  The  bacteria 
usually  present  are  the  colon  bacillus,  staphylococcus,  streptoccus, 
and  less  commonly  the  gonococcus,  typhoid  bacillus,  and  the  tubercle 
bacillus.  The  colon  bacillus,  the  tubercle  bacillus,  and  the  gono- 
coccus are  usually  found  in  acid  urine,  the  others  in  alkaline  urine, 
b. — Local  irritation  is  the  result  of  cold,  injury,  calculi,  foreign  bodies, 
external  pressure  from  tumors,  lithemia  and  irritating  drugs,  such 
as  turpentine  and  cantharides.  Inflammation  from  any  of  these 
causes,  even  though  primarily  aseptic,  is  almost  certain  to  become 
infective,  and  then  the  infection  assumes  the  predominant  role, 
c.' — Obstruction  from  any  cause  (see  "Retention  of  Urine")  results 
in  retention  and  decomposition  of  the  urine. 

The  symptoms  of  acute  cystitis  are  pain  in  the  hypogastrium 
and  perineum,  more  marked  at  the  end  of  urination,  which  is  fre- 
quent, urgent,  and  associated  with  tenesmus;  tenderness  of  the 
bladder,  elicited  by  hypogastric  or  rectal  palpation;  turbid,  usually 
acid  urine,  containing  mucus,  pus,  and  sometimes  blood;  and  fever 
due  to  toxemia.  Cystoscopic  examination  is  generally  contrain- 
dicated.  Recovery  is  the  rule,  but  the  inflammation  may  become 
chronic,  or  rarely  cause  death  from  toxemia,  peritonitis,  or 
pyelonephritis. 

The  treatment  is  removal  of  the  cause,  rest  in  bed  with  the  hips 
elevated,  hot  applications  to  the  hypogastrium,  hot  hip  baths, 
liquid  diet,  alkaline  diuretics,  and,  when  needed,  opium  and  bella- 
donna suppositories.     Urinary  antiseptics  are  generally  employed, 


URINARY    ORGANS  873 

but  probably  ha\e  little  inlliience  on  the  course  of  the  disease. 
Hcxamcthylenaniine,  because  of  its  irritating  qualities,  is  con- 
traimlicated;  likewise  instrumentation,  unless  there  is  retention  of 
urine. 

Chronic  cystitis  follows  the  acute  form  or  is  such  from  the  begin- 
ning. The  symptoms  are  those  of  the  acute  form,  but  much  milder  in 
degree.  The  urine  may  be  acid,  but  is  much  more  commonly 
alkaline,  ammoniacal,  fetid,  and  turbid  with  phosphates,  mucus, 
and  pus;  phosphatic  calculi  are  frequently  formed.  The  general 
health  becomes  impaired  and  there  is  constant  danger  of  septic 
pyelonephritis.  The  bladder  walls  are  thickened  and  sometimes 
sacculated.  Ulcers  may  form  and  occasionally  perforation  ensues. 
The  diagnosis  of  chronic  cystitis  should  never  be  made  without 
cystoscopic  examination,  as  the  symptoms  of  this  affection  may  be 
due  to  lesions  of  the  kidney,  especially  tuberculosis.  Further, 
cystitis  may  exist  without  subjective  symptoms,  the  only  external 
evidence  being  the  urinary  changes. 

The  treatment  is  that  of  the  cause.  The  patient  should  drink 
plenty  of  water.  The  favorite  urinary  antiseptics  (see  ''Gonor- 
rhea") are  hexamethylenamine  (gr.  lo  t.d.)  and  sandalwood  oil 
(10  minims  t.d.) ;  as  the  former  yields  formalin  only  in  acid  urine 
it  should,  if  the  urine  is  alkaline,  be  combined  with  acid  sodium 
phosphate,  gr.  lo  t.d.,  unless  the  phosphate  produces  diarrhea.  The 
bladder  may  be  irrigated  daily  with  boric  acid  solution  (gr.  15  to 
the  ounce),  silver  nitrate  (i  to  10,000),  or,  with  one  of  the  other 
silver  salts.  When  the  cause  cannot  be  ascertained  and  no  improve- 
ment follows  treatment  like  the  foregoing,  the  bladder  may  be 
opened  suprapubicly,  explored  and  drained. 

Pericystitis,  or  inflammation  of  the  perivesical  cellular  tissue, 
may  be  due  to  affections  of  the  bladder,  prostate,  rectum,  uterus. 
Fallopian  tubes,  pelvic  bones,  and  less  frequently  to  extension 
from  distant  parts,  e.g.,  the  appendix  vermiformis,  dorsal  or  lumbar 
vertebrae.  The  inflammation  may  terminate  in  resolution,  the 
formation  of  adhesions,  or,  most  frequently,  in  suppuration,  the 
abscess  discharging  into  the  bladder,  the  bowel,  or  externally. 
The  symptoms  are  those  of  the  causative  lesion,  with  irritability  of 
the  bladder  and  sepsis.  Induration  can  be  detected  by  external, 
vaginal,  or  rectal  palpation.  The  treatment  is  that  of  the  cause, 
with,  if  suppuration  occurs,  drainage  of  the  abscess,  either  above 
the  pubes  or  through  the  perineum. 

Diverticula  of  the  bladder  may  be  single  or  multiple,  and  com- 
posed of  mucosa  alone  or  o(  the  mucous  and  the  muscular  coats. 


874  MANUAL   OF   SURGERY 

In  the  so-called  double,  or  hour-glass  bladder,  the  diverticulum  is 
as  large  as  or  larger  than  the  bladder  itself.  The  favorite  sex  for 
diverticula  is  the  male,  the  favorite  location  the  base  of  the  bladder 
near  the  ureteral  orifices,  more  often  the  left.  In  one  case  we 
found  a  diverticulum  filled  with  small  calculi  in  the  sac  of  a  direct 
inguinal  hernia.  Diverticula  are  congenital  or  acquired,  in  the 
latter  instance  often  due  to  or  associated  with  obstruction  to  the 
outflow  of  the  urine,  particularly  from  prostatic  hypertrophy.  The 
pouch  may  contain  stones,  and  is  often  inflamed,  the  inflammation 
sometimes  extending  to  the  extravesical  structures;  pericystitis. 
Pyelonephritis,  perforation,  and  carcinoma  also  are  possibilities. 
The  Symptoms  are  those  of  chronic  cystitis.  After  micturating 
the  patient  may  feel  that  the  bladder  is  not  empty,  and  then,  perhaps 
after  a  change  in  position,  void  a  quantity  of  fetid  purulent  urine. 
The  cystoscope  generally  reveals  the  pouch,  but  may  fail  to  do  so 
when  the  orifice  is  minute  or  behind  a  large  prostate;  in  these  cases 
cystograms,  taken  anteroposterior^  and  laterally,  are  of  great 
service.  Judd  advises  looking  for  diverticula  in  all  cases  in  which 
the  bladder  is  drained  for  cystitis,  even  though  preHminary  in- 
vestigations for  this  condition  are  negative,  and  adds  that  one 
should  always  suspect  a  diverticulum  when  cystitis  with  residual 
urine  does  not  respond  to  ordinary  treatment  after  a  prostatectomy. 
The  treatment  is  excision.  A  suprapubic  cystotomy  is  performed, 
and  a  finger  passed  into  the  sac,  which  is  isolated  by  |5aravesical 
dissection,  without,  if  possible,  opening  the  peritoneum.  The  sac  is 
then  amputated,  the  vesical  opening  closed  with  sutures,  and  the 
space  as  well  as  the  bladder  drained.  Some  operators  prefer  inverting 
the  pouch  into  the  bladder,  suturing  the  vesical  wall  at  the  point 
corresponding  to  the  orifice  of  the  diverticulum,  and  then  excising 
the  sac  from  within  the  bladder.  A  concomitant  hypertrophied  pro- 
state may  be  removed  at  the  same  time,  or  left  for  a  later  operation. 
Tuberculosis  of  the  bladder  is  rarely  primary,  but  almost  always 
secondary  to  tuberculosis  of  the  kidney,  epididymis,  seminal  vesicle, 
prostate,  or  testicle.  It  is  more  frequent  in  men  than  in  women. 
The  tubercles  break  down  and  form  ulcers.  The  symptoms  are  those 
of  chronic  cystitis,  gradually  become  more  severe  and  intractable, 
until,  in  the  later  stages,  the  bladder  is  in  a  state  of  almost  constant 
spasm,  the  capacity  being  reduced  to  two  or  three  ounces,  hence 
cystoscopic  examination  is  often  impossible.  The  urine  contains 
pus,  blood,  and  tubercle  bacilli,  and,  as  the  bacilli  do  not  decompose 
the  urine,  it  is  acid  in  reaction,  unless  there  is  mixed  infection.  The 
prognosis  is  unfavorable. 


URINARY    ORGANS  875 

The  treatment  is  attention  to  the  general  health  as  in  tuberculosis 
elsewhere,  and  local  treatment  as  in  other  forms  of  chronic  cystitis. 
The  injection  of  iodoform  emulsion  has  been  advised.  Sometimes 
removal  of  the  source  of  infection,  e.g.,  the  kidney  or  the  testicle, 
is  followed  by  amelioration  or  even  complete  recovery.  When 
these  measures  fail  the  bladder  may  be  opened  above  the  pubes 
and  drained,  and  perhaps  the  ulcers  curetted,  or  touched  with 
carbolic  acid. 

Ulcers  of  the  bladder,  apart  from  syphilis,  tuberculosis,  and 
neoplasms,  may  be  due  to  injury,  burning  with  the  cystoscope,  or 
cystitis.  A  solitary  ulcer,  usually  situated  at  the  base  of  the  bladder, 
sometimes  occurs  in  anemic  women.  It  occasionally  perforates, 
and  has  been  compared  to  a  peptic  ulcer.  The  symptoms  of  ulcer 
of  the  bladder  are  those  of  chronic  cystitis,  the  diagnosis  being 
made  by  the  cystoscope.  The  treatment  is  that  of  chronic  cystitis. 
Ulcers  have  been  curetted  and  local  applications  made  through  an 
operating  cystoscope.  In  progressing  cases  the  bladder  should  be 
opened,  the  ulcers  curetted  and  cauterized,  and  drainage  established; 
perforation  is  treated  in  the  same  way  as  rupture  of  the  bladder. 

Tumors  of  the  bladder  are  uncommon,  and  are  more  often 
encountered  in  men  than  in  women.  The  most  frequent  variety 
is  papilloma;  it  has  projecting  fimbriae,  and  is  apt  to  undergo  carcino- 
matous degeneration.  Carcinoma  also  is  comparatively  frequent, 
and  those  who  work  in  anihn  factories  seem  to  have  a  special  pre- 
disposition to  this  form  of  growth.  Sarcoma,  angioma,  myoma, 
and  fibroma  are  very  rare.  The  base  of  the  bladder  is  the  portion 
usually  attacked.  The  symptoms  in  the  beginning  are  often  slight. 
Attacks  of  profuse  painless  hematuria,  most  marked  at  the  end  of 
micturition,  are  of  great  significance.  Later  cystitis  arises.  Oc- 
casionally a  portion  of  the  tumor  is  passed  with  the  urine.  Sudden 
interruption  of  the  urinary  stream  may  occur  from  transient 
blocking  of  the  internal  meatus,  hydronephrosis  from  obstruction 
to  the  ureter.  Unilateral  pain,  sometimes  reflected  to  the  hip,  loin, 
or  down  the  thigh  usually  means  that  the  growth  has  extended 
beyond  the  bladder.  The  diagnosis  is  made  with  the  cystoscope, 
the  use  of  which  may  be  difficult  on  account  of  hemorrhage.  Large 
tumors  may  be  palpated  by  bimanual  examination,  between  the 
hand  above  the  pubes  and  a  finger  in  the  rectum.  Malignant 
growths  may  often  be  felt  with  the  sound,  particularly  if  incru- 
stated  with  phosphatic  deposits.  The  prognosis  is  bad,  even 
benign  growths,  if  unmolested,  may  be  fatal  from  bleeding. 

The  treatment  of  benign  tumors  by  f  ulguration  is  recommended 


876  MANUAL    OF    SURGERY 

by  some  surgeons,  the  spark  being  applied  by  means  of  an  insulated 
wire  introduced  through  the  cystoscope.  Recurrence  and  cancer- 
ization  are  frequent  after  fulguration.  In  most  tumors  of  the 
bladder,  however,  the  best  procedure  is  suprapubic  cystotomy. 
If  the  growth  is  pedunculated,  it  may  be  removed  with  the  curette 
and  the  base  cauterized.  It  it  is  malignant  and  of  small  size,  a 
portion  of  the  bladder  wall  should  be  removed  and  the  wound  sutured. 
Partial  cystectomy  may  be  done,  as  suggested  by  Harrington, 
through  the  peritoneal  cavity.  Removal  of  the  entire  bladder, 
with  implantation  of  the  ureters  into  the  vagina  or  rectum,  has  been 
successfully  accomplished.  If  the  growth  is  found  to  be  inoperable, 
suprapubic  drainage  may  be  established  or  bilateral  nephrostomy 
or  ureterostomy  performed. 

The  X-rays  or  radium  also  may  be  used  for  palliative  purposes. 

Foreign  bodies  usually  gain  entrance  to  the  bladder  through  the 
urethra,  being  introduced  by  the  patient,  or  resulting  from  the  break- 
ing of  instruments,  but  they  may  find  their  way  into  the  viscus  also 
through  ulceration  or  injury  of  its  walls.  The  symptoms  are  those  of 
cystitis.  If  allowed  to  remain,  the  foreign  body  is  apt  to  become 
the  nucleus  of  a  calculus.  The  diagnosis  may  be  made  by  means  of 
sound,  the  cystoscope,  the  X-ray,  and  occasionally  by  bimanual 
examination.  Foreign  bodies  should  be  removed  with  forceps 
through  the  cystoscope,  with  the  lithotrite,  with  the  finger  or  forceps 
after  dilatation  of  the  urethra  (in  the  female),  or  by  supra-pubic 
cystotomy. 

Vesical  calculus,  or  stone  in  the  bladder,  is  composed  of  the  same 
materials  and  due  to  the  same  causes  as  renal  calculus  (q.v.),  in  fact 
most  vesical  stones  have  descended  from  the  kidney  and  then  in- 
creased in  size.  Those  originating  in  tlie  bladder  usually  consist 
of  phosphates,  precipitated  as  the  result  of  alkaUne  decomposition 
of  the  urine  consequent  upon  chronic  cystitis,  hence  renal  stones 
lodging  in  the  bladder  and  foreign  bodies  from  other  sources  gener- 
ally have  a  phosphatic  coating.  Vesical  calculi  vary  greatly  in  size, 
but  are  usually  single,  spherical,  ovoid,  or  disc-like  in  shape,  although 
there  may  be  a  groove  corresponding  to  the  inter-ureteral  bar  or, 
when  the  stone  is  partly  in  the  urethra,  a  constriction  resembling 
that  of  an  hour-glass.  An  elongated  concretion  is,  as  a  rule,  the 
result  of  a  foreign  body,  e.g.,  a  hair-pin.  a  pencil,  a  fragment  of  a 
catheter.  ^Multiple  stones  are  often  faceted  from  mutual  pressure. 
Stone  is  common  in  young  boys  because  of  the  small  caliber  of  the 
urethra,  and  in  old  men  because  of  the  frequency  of  residual  urine 
and  cystitis.     Women  are  comparatively  free  from  the  aft'ection,  as 


URINARY   ORGANS  877 

the  urethra  is  short  and  of  large  caUber,  tliiis  permitting  the  ready 
passage  of  small  stones. 

The  symptoms  are  pain,  whieh  is  worse  just  after  urination,  when 
the  stone  is  forced  down  upon  the  sensitive  tiigone,  and  which  may 
be  referred  to  the  perineum,  back,  down  the  thighs,  and  especially 
to  the  glans  penis;  frequent  micturition;  often  hematuria,  particu- 
larly at  the  end  of  micturition;  sometimes  sudden  transient  cessa- 
tion of  the  flow  of  urine,  caused  by  the  stone  falling  against  the  inter- 
nal meatus;  and  possibly  retention  or  incontinence  of  urine,  reten- 
tion from  impaction  of  the  stone  in  the  urethra,  incontinence  from 
propping  open  of  the  internal  meatus  or,  especially  in  children,  from 
extreme  irritability  of  the  bladder.  The  first  three  symptoms 
are  intensified  by  exercise  or  jolting,  and  vary  in  degree  according 
to  the  size  and  shape  of  the  stone  and  the  sensitiveness  of  the  mucous 
membrane.  Occasionally  the  history  of  "gravel"  or  of  renal  colic 
may  be  obtained.  Cystitis  may  either  precede  or  follow  stone  for- 
mation. Hernia,  hemorrhoids,  or  prolapse  of  the  rectum  may  be 
induced  by  straining,  and  priapism  is  sometimes  observed.  In 
children  incontinence  or  constant  pulling  at   the  foreskin  should 


Fig.  477. — Stone  sound. 

always  suggest  calculus.  The  diagnosis  is  made  by  sounding,  by 
the  cystoscope,  and  by  the  X-ray,  and  occasionally  a  stone  may  be 
felt  through  the  vagina  or  the  rectum.  The  sound  (Fig.  477)  is 
introduced,  as  described  under  "Stricture  of  the  Urethra,"  with  the 
patient  in  the  recumbent  posture,  the  bladder  being  partly  filled 
with  urine  or  boric  solution.  The  handle  should  be  marked  on  the 
side  towards  which  Ihe  beak  of  the  instrument  project?.  The 
instrument  is  drawn  backwards  and  forwards,  rotated  to  each  side, 
and  finally  turned  downwards,  thus  exploring  the  whole  bladder. 
The  stone  is  detected  by  a  click,  which  may  be  felt  and  sometimes 
heard.  The  sound  may  fail  to  discover  a  stone  which  is  encysted 
in  the  bladder  wall,  lies  behind  a  large  prostate,  or  is  coated  with 
mucus.  The  size  of  the  stone  can  be  measured  with  a  lithotrite.  A 
small  stone  which  eludes  the  sound  may  be  discovered  by  using  a 
Bigelow  evacuator;  the  suction  causes  the  stone  to  strike  against 
the  end  of  the  instrument.  As  vesical  and  renal  stones  coexist  so 
frequently,  the  examination  should  not  be  regarded  as  complete 
until  both  kidneys  and  both  ureters  have  been  investigated. 


878 


MANUAL   OF    SURGERY 


The  treatment  is  removal  of  the  stone  by  litholapaxy,  or  by 
suprapubic  lithotomy. 

Litholapaxy,  or  crushing  of  the  stone  and  removal  of  the  frag- 
ments is  to  be  chosen  in  all  cases  in  which  the  following  contra- 
indications are  not  present:  Obstructions  to  the  passage  of  the 
instrument  (e.g.,  stricture  and  enlarged  prostate),  severe  cystitis, 
sacculated  bladder,  greatly  contracted  bladder  (holding  less  than 
four  ounces),  great  irritability  of  the  urethra  (as  shown  by  chills 


Pig.   478. — Thompson's  modification  of  Civiale's  lithotrite. 

after  instrumentation),  and  large  (above  two  inches  in  diameter), 
very  hard,  or  encysted  calculus.  Recurrence  is  more  frequent 
after  this  operation  than  after  Hthotomy,  the  nucleus  of  the  new 
stone  being  formed  by  a  fragment  which  has  been  left  behind. 
The  mortahty  is  betw^een  3  and  4  per  cent,  in  the  hands  of 
the  most  skilled.  The  patient  is  anesthetized,  placed  on  the  back 
with  the  thighs  separated,  and  the  bladder  irrigated  with  boric 
solution,  six  ounces  of  which  should  be  allowed  to  remain  in  the 

viscus.  The  lithotrite  (Fig.  478) 
is  introduced,  and  the  stone  caught 
and  crushed  between  the  blades, 
which  are  pressed  together  by 
screwing  the  handle.  The  larger 
fragments  are  crushed  in  the  same 
manner.  The  crushing  is  always 
done  in  the  middle  of  the  bladder, 
with  the  blades  up,  in  order  to 
avoid  injury  to  the  bladder  wall. 
The  evacuator  (Fig.  479)  is  next  introduced,  and  the  debris  re- 
moved by  alternate  pressure  and  relaxation  of  the  rubber  bulb,  the 
fragments  falling  into  the  glass  receptacle  attached  to  the  apparatus. 
If  fragments  remain  which  are  too  large  to  pass,  the  lithotrite  must 
be  reintroduced.  Severe  bleeding  may  be  checked  by  the  intro- 
duction of  adrenalin  solution  i  to  10,000.  If  the  blades  lock,  it  may 
become  necessary  to  open  the  bladder  through  the  perineum  or  above 
the  pubes.  At  the  completion  of  the  operation  the  bladder  should 
be  inspected  with  the  cystoscope,  to  make  sure  that  all  fragments 


Pig.  479. — Evacuator  in  position  in  the 
bladder.     (Rose  and  Carless.) 


URINARY    ORGANS 


879 


have  been  removed.  'Hie  after  treatment  consists  in  rest,  warmth, 
plenty  of  lluid,  and  uiinary  antisei:)tics.  Morj^hin  may  be  given 
for  pain,  ([uinin  for  chills,  irrigations  for  cystitis. 

Suprapubic  cystotomy,  when  performed  for  the  removal  of  stones, 
is  called  suprapubic  lithotomy,  and  is  the  operation  of  choice  when 
litholapaxy  is  contraindicated,  or  when  the  surgeon  lacks  the  neces- 
sary instruments  of  skill.  The  patient  is  prepared  as  for  any  abdo- 
minal operation,  including  shaving  the  pubes.  The  capacity  of  the 
bladder    should    have   been    previously    tested,    and    at    the    time 


Fig.  480. — Stone  forceps. 

of  operation  the  bladder  should  be  irrigated  and  filled  with  boric 
acid  solution,  or,  as  some  surgeons  prefer,  filled  with  air.  A  catheter 
is  tied  about  the  penis,  in  order  to  prevent  the  escape  of  fluid,  and 
the  patient  placed  in  the  Trendelenburg  position.  These  maneuvers 
displace  the  vesical  fold  of  the  peritoneum  upwards,  and  thus  per- 
mit extraperitoneal  exposure  of  the  bladder.  The  bladder  may  be 
pushed  upwards  against  the  belly  wall  by  introducing  a  rubber 
bag  into  the  rectum  and  distending  it  with  air  or  water,  but  this  is 
unnecessary  and  sometimes  dangerous.     In  our  own  work  vesical 


Fig.  481. — Stone  scoop. 

distention  and  the  rectal  bag  are  omitted.  A  three  inch  incision 
is  made  in  the  median  line  from  the  symphysis  pubis  upwards,  the 
prevesical  fat  separated,  and  the  bladder  recognized  by  its  longi- 
tudinal muscular  fibers  and  its  gloublar  form.  Two  sutures  are 
passed  through  the  bladder  wall  to  act  as  tractors  and  a  longitudinal 
incision  made  between  them.  Stones  may  be  removed  with  the 
finger,  forceps  (Fig.  480),  or  scoop  (Fig.  481),  or  if  the  bladder  has 
been  opened  for  other  reasons,  the  lesions  should  be  dealt  with  as 
described  elsewhere.  A  self  retaining  retractor  and  a  head  light  are 
of  great  service  when  one  wants  to  inspect  theinterior  of  the  viscus, 


88o 


MANUAL   OF    SURGERY 


e.g.,  in  the  removal  of  a  tumor.  If  the  bladder  is  not  infected, 
the  wound  may  be  closed  by  two  layers  of  Lembert's  sutures  of 
catgut,  the  incision  in  the  soft  parts  approximated,  leaving  space  for  a 
catheter  passed  into  the  bladder  through  the  urethra.  If  the  bladder 
is  infected,  the  wound  in  its  wall  may  be  sewed  to  the  fascia,  or  it  may 
be  closed  with  catgut  sutures  which  invert  it  about  a  rubber  tube, 
several  of  the  sutures  passing  through  the  tube,  which  should  be 
long  enough  to  syphon  the  urine  to  a  receptacle  beneath  the  bed. 
The  surgeon  must  not  forget  to  remove  the  tube  encircHng  the  penis, 
else  strangulation  and  gangrene  may  follow. 

Perineal  cystotomy  {perineal  section)  is  sometimes  performed  for 
drainage  and  prostatic  enlargement,  rarely  for  exploration,  the  re- 
moval of  growths  or  the  extraction  of  calculi;  in  the  last  instance 
it  is  called  perineal  lithotomy,  median  or  lateral,  according  to  the 
position  of  the  incision.  The  perineum  is  shaved  and  disinfected 
and  the  patient  placed  in  the  lithotomy  position,  i.e.,  on  the  back 

with  the  pelvis  raised  and  the  thighs 
flexed  on  the  abdomen.  The  bladder 
is  irrigated  and  left  partly  distended 
with  the  solution.  In  median  lithotomy 
a  staff  with  a  median  groove  on  its 
convex  side  is  passed  into  the  bladder, 
and  a  median  incision  made  from  just 
behind  the  scrotum  to  within  one  inch 
of  the  anus.  The  membranous 
urethra  is  opened  on  the  staff,  and  the  finger  passed  into  the  bladder 
by  dilating  the  prostatic  urethra.  If  more  room  is  required  the 
prostate  may  be  incised  in  the  middle  Kne  posteriorly.  A  calculus 
may  be  removed  with  forceps  or  scoop,  or  if  too  large  to  be  with- 
drawn whole,  it  may  first  be  fragmented  with  the  lithotrite.  A 
drainage  tube  is  then  introduced  into  the  bladder  through  the  wound. 
If  a  rubber  tube  is  employed  it  should  be  sutured  to  the  skin;  the 
special  metal  perineal  tube  shown  in  Fig.  482  is  fastened  in  place  by 
tapes.  Ordinarily  the  drainage  tube  may  be  removed  in  forty- 
eight  hours.  The  wound  is  covered  with  dressings,  held  in  place 
by  a  T-bandage.  Lateral  lithotomy  is  rarely  performed  at  the  present 
time,  having  been  displaced  by  the  operations  previously  described. 
A  staff  with  a  groove  on  the  left  side  is  introduced  into  the  bladder. 
The  incision  begins  one  and  one-half  inches  above  the  anus,  just  to  the 
left  of  the  middle  line,  and  extends  downwards  and  outwards  to  a 
point  just  outside  of  the  middle  of  a  line  from  the  anus  to  the  tuber 
ischii.     The  knife  enters  the  groove  on  the  staff  in  front  of  the  pros- 


FiG.  482. — Watson's  perineal  tube. 


URINARY    ORGANS  88 1 

tate  and  severs  the  left  lobe  of  that  organ.     The  rest  of  the  operation 
is  much  the  same  as  median  lithotomy. 

Calculus  in  the  female  is  rare,  and  is  usually  due  to  phosphatic 
deposits  on  a  foreign  body,  often  introduced  by  the  patient.  If 
small  it  may  be  removed  by  the  linger  or  forceps,  after  dilating  the 
urethra.  If  this  is  injudicious,  litholapaxy  should  be  performed. 
Very  large  stones  may  be  removed  by  suprapubic  cystotomy.  Vagi- 
nal cystotomy  is  inadvisable  because  of  the  danger  of  vesicovaginal 
fistula. 


56 


CHAPTER  XXX 


GENITAL  ORGANS 


URETHRA  AND  PENIS 

Congenital  Malformations. — Narrow  meatus  rarely  causes 
symptoms  and,  as  a  rule,  is  brought  to  the  surgeon's  attention  only  when 
it  is  desirable  to  introduce  instruments  for  other  reasons.  When 
necessary  the  meatus  may  be  enlarged  by  cutting  downwards  with  a 
blunt  pointed  bistoury  {meatotomy) ,  the  parts  being  separated  each 
day  by  a  probe  in  order  to  prevent  union.     Congenital  stricture  may 


Fig.  483. — Epispadias. 


Fig.  484. — Fracture  of  penis. 


occur  at  the  outer  end  of  the  fossa  navicularis  and  in  the  membranous 
urethra.  Occlusion  of  the  urethra  may  be  due  to  a  septum,  which 
should  be  perforated.  The  urethra  may  be  absent,  leading  to 
early  death  unless  there  is  a  congenital  urinary  fistula  at  the  umbili- 
cus or  into  the  rectum  or  perineum.  Epispadias  (Fig.  483)  is  a 
congenital  deformity  in  which  the  urethra  opens  on  the  dorsum  of  the 
penis.  Complete  epispadias,  i.e.,  when  the  whole  urethra  is  exposed 
on  the  dorsum  of  the  penis,  is  always  associated  with  extroversion  of 
the  bladder.  The  worst  feature  of  the  severer  cases  is  incontinence 
of  urine.     In  Thiersch's  operation  the  balanic  and  penile  urethrae  are 


GENITAL  ORGANS 


883 


first  constructed  by  lateral  llai)s  (Fig.  485),  and  at  a  later  period,  the 
defect  at  the  foot  of  the  penis  and  that  at  the  corona  are  closed  as 
as  shown  in  Fig.  486.  Hypospadias,  a  congenital  condition  in  which 
the  floor  of  the  urethra  is  defecti\e,  is  much  more  common.  There 
are  three  types:  in  the  halaiiik,  the  urethra  opens  just  behind  the 
glans;  in  the  penile,  on  the  under  surface  of  the  penis;  in  the  perineal, 
in  the  perineum,  the  scrotum  being  cleft,  and  the  penis  rudimentary. 
In  the  last  form  the  testicles  may  remain  within  the  abdomen  and  the 
child  be  mistaken  for  a  female.  Hypospadias  does  not  cause  incon- 
tinence of  urine.  When  the  opening  is  a  short  distance  behind  the 
glans,  the  urethra  may  be  freed  from  its  surroundings  and  drawn 


Fig.  485.  Fig.  486. 

Figs.  485  and  486. — Thiersch's  operation,  cc.  (Fig.  485) ,  Incision  in  prepuce  through 
which  glans  is  thrust  (Fig.  486),  so  that  prepuce  may  be  used  as  flap  to_close  defect 
between  the  balanic  and  penile  urethrae.     (Esmarch  and  Kowalzig.) 

through  a  perforation  in  the  glans,  where  it  is  sutured  (Beck's  opera- 
tion). In  other  cases  the  defect  may  be  remedied  by  an  operation 
similar  to  that  of  Thiersch  for  epispadias.  Free  venous  transplanta- 
tion for  hypospadias  is  a  failure.  More  promising  is  the  suggestion 
of  Cantas.  After  diverting  the  urine  through  a  suprapubic  or 
perineal  fistula,  a  sufficient  length  of  the  internal  saphenous  vein  with 
the  overlying  skin  in  dissected  from  the  thigh,  remaining  attached, 
however,  at  its  upper  end.  The  lower  end  of  the  liberated  vein  is 
sutured  to  the  urethral  meatus,  and  at  a  later  period  the  pedicle 
of  the  flap  is  severed,  and  the  skin  sutured  to  the  inferior  surface  of 
the  penis.  The  fibrous  bands  which  curve  the  penis  downwards 
should  be  divided  previous  to  any  operation  for  hypospadias. 


S84  MANUAL   OF    SURGERY 

Rupture  of  the  urethra  usually  takes  place  at  the  bulb,  as  the 
result  of  falling  astride  of  some  hard  object.  The  membranous 
urethra  may  be  torn  in  fracture  of  the  pelvis,  the  penile  urethra  in 
fracture  of  the  penis  during  erection.  The  urethra  may  give  way 
way  also  behind  a  stricture,  as  the  result  of  ulceration  or  straining. 
The  rupture  may  be  complete  or  partial.  The  symptoms  are  shock, 
pain,  tenderness,  bleeding  from  the  urethra,  inabihty  to  urinate,  and 
swelhng  caused  by  blood  and  urine.  At  a  later  period  the  phenomena 
of  septicemia  ensue,  owing  to  the  gangrenous  cellulitis  induced  by  the 
extra vasated  urine.  Extravasation  of  urine  is  influenced  by  the  situa- 
tion of  the  rupture.  When  the  rupture  is  above  the  upper  layer  of 
the  triangular  Hgament,  the  urine  extravasates  as  in  extraperitoneal 
rupture  of  the  bladder;  when  between  the  two  layers,  the  urine 
remains  localized  and  causes  an  abscess;  when  below  the  lower  layer, 
the  usual  situation,  the  urine  distends  the  scrotum,  penis,  and  ab- 
dominal wall,  but  does  not  pass  backwards,  owing  to  the  attachment 
of  the  fascia  of  Colles.  The  condition  is  to  be  distinguished  from 
contusion,  in  which  extravasation  does  not  occur,  and  in  which 
urination  is  usually  possible.  In  severe  lacerations  a  catheter  cannot 
be  introduced. 

The  treatment,  in  early  cases,  is  exposure  and  suture  of  the  torn 
urethra,  a  retention  catheter  being  passed  into  the  bladder  through 
the  urethra.  The  perineal  urethra  is  exposed  by  an  incision  identical 
with  that  for  median  lithotomy.  If  the  posterior  urethral  segment 
cannot  be  found,  the  bladder  should  be  opened  above  the  pubes  and 
retrograde  catheterization  performed.  The  wound  should  be 
drained  with  gauze;  additional  incisions  will  be  necessary  for  drainage 
if  the  urine  has  infiltrated  the  surrounding  tissues.  Traumatic 
stricture,  which  is  almost  inevitable  after  this  injury,  should  be 
anticipated  by  the  passage  of  sounds  every  second  day  after  the 
retention  catheter  has  been  removed,  i.e.,  at  the  end  of  lodays.  In 
late  cases,  which  are  always  septic,  the  bladder  should  be  drained  as 
after  perineal  lithotomy,  free  incisions  being  made  into  the  gan- 
grenous perineum  and  scrotum.  If  the  patient  survive,  repair  of  the 
urethra  may  be  attempted  after  the  sepsis  has  disappeared.  Con- 
tusions of  the  urethra  are  treated  by  external  applications  of  cold, 
rest  in  bed,  and  urinary  antiseptics.  The  catheter  should  not  be 
used  unless  there  is  retention  of  urine. 

Foreign  bodies,  such  as  a  portion  of  a  catheter  or  pencil,  when 
lodged  in  the  urethra,  partly  or  completely  obstruct  the  lumen,  and 
may  cause  ulceration,  periurethral  abscess,  and  extravasation  of 
urine.     They  may  be  detected  by  the  sound,  the  urethroscope,  the 


GENITAL    ORGANS  885 

X-ray,  and  sometimes  by  external  palpation.  Removal  is  effected 
by  forceps  when  the  foreign  body  is  in  the  penile  urethra,  or,  when 
this  is  not  possible,  by  external  incision.  In  the  latter  instance  the 
urethral  wound  should  be  sutured.  A  pin  which  has  been  pushed 
into  the  urethra  head-first,  may  be  removed  by  forcing  the  point 
through  the  lloor  of  the  urethra,  reversing  the  direction  of  the  pin, 
and  pushing  it  out  through  the  meatus.  An  impacted  calculus  is  often 
expelled  after  the  spasm  to  which  it  gives  rise  has  been  allayed  by  a 
hot  bath  and  an  opium  and  belladonna  suppository.  If  it  cannot  be 
expelled  it  should  be  treated  as  a  foreign  body. 

Urethritis  may  be  simple  or  specific.  Simple  urethritis  may  be 
due  to  any  of  the  pyogenic  bacteria,  except  the  gonococcus.  It  may 
be  induced  by  injury,  e.g.,  contusions,  wounds,  foreign  bodies,  rough 
instrumentation,  and  caustic  injections;  certain  substances  taken 
into  the  stomach,  e.g.,  alcohol  in  excess,  cantharides,  turpentine,  and 
potassium  iodid;  gout  or  rheumatism;  certain  skin  diseases,  e.g., 
herpes  and  eczema;  urethral  chancre  or  chancroid;  highly  acid  urine- 
contact  with  lochial,  leukorrheal,  or  menstrual  fluid;  infectious 
diseases;  tuberculous  ulceration;  masturbation;  sexual  excess;  and 
polypi.  The  symptoms  are  the  same  as  those  of  gonorrhea,  but 
usually  milder.  The  treatment  is  removal  of  the  cause,  diuretics, 
urinary  antiseptics,  and  in  some  cases  mild  astringent  injections. 

Specific  urethritis,  gonorrhea,  or  clap,  is  inflammation  of  the 
urethra  caused  by  the  gonococcus.  The  gonococcus  is  a  diplococcus 
looking  somewhat  like  a  coffee  bean,  and  occurring  both  within  and 
without  the  leukocytes  and  epithelial  cells.  It  may  be  stained  with 
methyl  or  gentian  violet,  and  does  not  take  the  Gram  stain,  a  point 
to  be  remembered  in  differentiating  it  from  pseudogonococci.  In 
doubtful  cases  cultural  methods  may  be  necessary  to  estabHsh  a 
diagnosis.  The  complement  fixation  test  for  gonorrhea,  although  too 
recent  to  be  given  a  fixed  status,  is  becoming  more  important, 
especially  in  the  diagnosis  of  systemic  infection.  A  negative  reac- 
tion, however,  does  not  exclude  the  disease.  Gonorrhea  is  acquired 
by  direct  contract,  but  no  breach  of  the  mucous  surface  is  necessary. 
The  organism  enters  the  epitheHal  cells  and  occasionally  the  sub- 
epithelial tissues,  causing  a  purulent  inflammation. 

The  symptoms  begin  after  a  period  of  incubation  varying  from 
one  to  fourteen  days.  At  first  there  is  itching  and  burning  in  the 
fossa  navicularis,  with  gluing  together  of  the  lips  of  the  meatus. 
During  the  acute  stage  the  meatus  is  red  and  swollen,  the  discharge 
thick  and  yellow.  There  is  burning  pain  on  micturition  {ardor 
urince).  which  may  pass  to  the  groin  or  perineum.     The  urinary 


886  MANUAL   OF   SURGERY 

stream  may  be  forked,  owing  to  the  swelling  of  the  mucous  mem- 
brane, but  retention  is  uncommon.  Owing  to  the  infiltration  of  the 
corpus  spongiosum,  erection  may  be  exceedingly  painful  and  the 
penis  markedly  curved  ichordee).  After  from  two  to  six  weeks  in  a 
favorable  case  the  discharge  becomes  serous  and  finally  disappears. 
In  the  female  the  vulva  and  vagina  as  well  as  the  urethra  are  in- 
volved, but  the  symptoms  are  usually  less  acute  than  in  the  male. 
Gonorrhea  varies  in  duration  and  intensity;  thus  the  discharge  may 
persist  but  a  week  or  ten  days  {abortive  gonorrhea) ,  or  the  manifesta- 
tions may  be  comparatively  mild  (subacute  gonorrhea)^  particularly 
in  those  who  have  had  previous  attacks.  In  a  certain  proportion  of 
cases  the  inflammation  extends  backwards  and  involves  the  mem- 
branous and  prostatic  portions  of  the  urethra  {posterior  urethritis) , 
whence  it  may  spread  to  the  bladder,  prostate,  seminal  vesicles,  or 
testicles.  Posterior  urethritis  is  usually  announced  by  frequent  and 
painful  micturition  and  often  by  perineal  pain.  If  the  patient 
urinates  into  two  glasses,  the  first,  holding  about,  two  ounces,  will 
contain  the  washings  of  the  entire  urethra,  while  the  second,  if 
turbid  with  pus,  will  indicate  posterior  urethritis,  the  pus  from  which 
flows  back  into  the  bladder.  Another  test  is  to  wash  out  the  anterior 
urethra  with  a  catheter,  after  which  purulent  urine  would  point  to 
posterior  urethritis. 

Chronic  gonorrhea  may  involve  the  anterior,  the  posterior,  or  the 
whole  urethra.  In  the  first  and  last  instances  the  most  important 
symptom  is  gleet,  i.e.,  a  slight  mucopurulent  discharge,  which  may  be 
observed  only  in  the  morning.  If  posterior  urethritis  alone  exists, 
there  may  be  no  discharge,  but  pus  or  threads  {Trip per/ aden)  will  be 
found  in  the  urine.  Chronic  anterior  urethritis  is  usually  per- 
petuated by  a  stricture,  a  suppurating  follicle,  or  a  spot  of  ulceration; 
posterior  urethritis  by  infection  of  the  prostatic  ducts. 

The  complications  of  gonorrhea  are  due  to:  (i)  extension  by  con- 
tinuity—hsdano-posihiih,  phimosis,  paraphimosis,  folliculitis,  peri- 
urethral abscess,  Cowperitis,  prostatitis,  vesiculitis,  epididymitis, 
cystitis,  pyelonephritis  (rare),  abscess  of  Bartholin's  glands,  endo- 
metritis, salpingitis,  ovaritis,  pelvic  peritonitis;  (2)  extension  by 
contiguity — cellulitis  (rare) ;  (3)  extension  by  the  lymphatics — lym- 
phangitis, buboes;  (4)  transmission  of  the  injection — proctitis,  rhinitis, 
conjunctivitis  (gonorrheal  ophthalmia),  stomatitis;  (5)  extension 
by  the  blood — arthritis  (gonorrheal  rheumatism),  gonorrheal  sclerotitis 
or  iritis  (independent  of  gonorrheal  ophthalmia),  and  inflammation 
of  the  tendon  sheaths,  muscles,  pleura,  pericardium,  endocardium, 
blood  vessels,  and  it  is  said  even  of  the  meninges,  nerves,  or  spinal  cord. 


GENITAL  ORGANS  887 

Prophylaxis  iiuludcs  the  use  of  Ihc  condom  during  sexual  inter- 
course. In  the  Navy  irrigations  of  the  anterior  urethra  with  potas- 
sium permanganate  have  been  employed,  also  the  "sanitary  tube," 
which  contains  an  ointment  consisting  of  calomel,  50  grams,  liquid 
vaselin.  So  cc,  and  lanolin,  70  grams.  The  nozzle  of  the  tube  is 
applied  to  the  meatus,  and  a  portion  of  the  ointment  forced  into  the 
urethra  by  compressing  the  tube,  which  is  collapsible.  The  remain- 
ing portion  of  the  ointment  is  rubbed  on  the  outside  of  the  penis 
(Henry).  "The  regulations  of  the  Surgeon  General  of  the  Army 
require  a  preliminary  washing  of  the  genitals  with  soap  and  water, 
and  the  injection  into  the  urethra  of  2  per  cent,  protargol  or  20  per 
cent,  argyrol,  which  must  be  retained  for  three  minutes,  and  the 
rubbing  of  calomel  ointment  (30  per  cent,  in  benzoated  lard)  into  the 
surface  of  the  entire  penis"  (G.  G.  Smith).  These  antiseptic  meth- 
ods are  of  the  greatest  value  during  the  first  few  hours  after  inter- 
course. 

The  treatment  of  acute  gonorrhea  is  greatly  facilitated  by  keeping 
the  patient  as  quiet  as  possible,  and  in  severe  cases  by  rest  in  bed. 
The  bowels  should  move  regularly  and  large  quantities  of  water  be 
taken.  The  diet  should  be  plain  and  unstimulating,  alcohol,  coffee, 
tea,  and  condiments  being  especially  interdicted.  The  patient 
should  wear  a  suspensory,  and  some  form  of  gonorrhea  bag  to  catch 
the  discharge;  a  piece  of  cotton  held  in  place  by  pulling  down  the 
foreskin  over  it,  is  useful  for  the  latter  purpose.  Sexual  excitement 
of  all  forms  must  be  prohibited,  and  the  penis  cleansed  twice  a  day  by 
soaking  in  warm  salt  solution.  A  hot  hip  bath  once  or  twice  a  day 
is  beneficial.  The  patient  should  be  warned  of  the  contagiousness 
of  the  discharge,  and  particularly  of  the  danger  of  gonorrheal  oph- 
thalmia; the  hands  should  be  kept  clean,  and  all  towels  used  by  the 
patient  kept  apart  from  those  used  by  others.  The  so-called  abortive 
treatment,  in  which  strong  antiseptic  solutions  are  injected  into  the 
urethra,  is  dangerous.  Internal  treatment  usually  consists  in  the 
administration  of  urinary  antiseptics,  e.g.,  hexamethylenamine 
(grains  10  t.  d.),  salol  in  the  same  dose,  boric  acid  (grains  15  t.  d.), 
or  methylene  blue  (grains  2  t.  d.) ;  alkalies,  particularly  when  ardor 
urinae  is  marked,  e.g.,  carbonate  of  soda,  or  potassium  citrate  or 
acetate;  and  balsamics,  e.g.,  oleoresin  of  copaiba,  oleoresin  of  cubebs, 
and  oil  of  sandalwood,  each  of  which  may  be  given  in  from  5  to  10 
minim  doses  t.  d.  in  capsules.  The  balsamics  may  upset  the  stomach 
and  copaiba  may  cause  an  urticarial  erythema;  they  are  most  useful 
towards  the  end  of  an  attack  or  in  chronic  cases.  Bromid  of  potas- 
sium or  lupelin,  20  to  40  grains  on  retiring,  is  the  most  effective 


MANUAL   OF   SURGERY 

remedy  for  chordee;  the  painful  erection  itself  may  be  relieved  with 
ice  water.  Injections  may  be  antiseptic  or  astringent;  the  former 
may  be  used  from  the  beginning,  the  latter  in  the  declining  stages. 
Any  injection  which  causes  much  pain  is  too  strong  and  must  be 
diluted  or  discarded.  The  syringe  should  be  blunt  pointed  and  hold 
about  three  or  four  drams.  The  injection  should  be  given  after  each 
urination,  and  the  fluid  held  in  the  urethra  for  three  minutes  by 
compressing  the  meatus.  Of  the  antiseptic  injections  may  be  men- 
tioned argyrol  (silver  vitellin)  i  to  5  per  cent.,  protargol  3^^  to  i  per 
cent.,  and  potassium  permanganate  from  i  to  10,000  to  i  to  1000. 
The  following  are  astringent  injections;  zinc  sulphate,  grains  10, 
bismuth  subnitrate,  powdered  acacia,  each  i  dram,  and  water  3 
ounces;  tincture  of  catechu,  10  minims  to  the  ounce  of  water;  and 
liq.  plumbi  subacetat.  dil.  Janet's  irrigation  method  consists  in 
washing  out  the  urethra  by  means  of  a  fountain  syringe,  which  is 
connected  with  a  blunt  nozzle  to  be  applied  to  the  meatus.  Per- 
manganate of  potassium  i  to  4000  or  weaker,  is  used  at  first,  the 
reservoir  being  two  feet  above  the  penis,  and  the  irrigations  given 
twice  a  day.  To  avoid  the  danger  of  forcing  infection  from  the  an- 
terior to  the  posterior,  the  membranous  urethra  or  bladder,  pressure 
should  be  made  upon  the  urethra  at  the  triangular  ligament  during 
the  injection;  sitting  upon  the  edge  of  a  chair  with  a  folded  towel 
pressing  upon  the  perineum  is  the  method  usually  employed.  Later 
the  strength  of  the  solution  is  increased,  and  the  irrigations 
given  once  a  day.  The  posterior  urethra  may  be  irrigated 
by  raising  the  reservoir  to  the  height  of  five  feet,  the  fluid  entering 
the  bladder,  which,  when  full,  is  emptied  by  urination.  When  the 
acute  symptoms  subside  the  irrigations  are  abandoned  and  astringent 
injections  employed.  The  method  is  highly  recommended  by  some 
and  condemned  by  others,  who  believe  that  it  increases  the  danger  of 
complications.  Gonorrhea  in  the  female  is  treated  on  the  same 
principles  as  in  the  male  (see  vulvitis,  vaginitis,  etc.).  Gonorrhea 
is  cured  when  there  are  no  clinical  evidences  of  the  disease  for  two 
weeks,  and  when  gonococci  cannot  be  found  in  the  mucus  expressed 
from  the  prostate,  the  seminal  vesicles,  and  the  urethra. 

The  treatment  of  chronic  gonorrhea  involves  a  careful  examina- 
tion to  determine  the  cause  of  the  persistence  of  the  discharge.  Any 
constitutional  malady;  particularly  gout  or  rheumatism,  should 
receive  appropriate  treatment.  Localized  patches  of  inflammation 
will  prove  to  be  very  sensitive  on  the  introduction  of  a  bulbous 
bougie,  which  will  detect  also  any.  narrowing  of  the  urethra,  and  will 
give  some  information  by  the  character  of  the  discharge  which  is 


GENITAL    ORGANS  889 

brought  out  in  front  of  the  bulb.  The  urethroscope,  which  is  a 
cyHmlrical  s])oculum  with  a  small  electric  lamp  at  the  end,  allows 
visual  inspection  of  the  entire  urethra,  the  walls  of  the  canal  proplas- 
ing  over  the  end  of  the  tube  as  it  is  withdrawn.  Many  urologists 
prefer  a  urethroscope  which  permits  dilatation  of  the  urethra  with 
air  or  water.  It  is  inserted  after  disinfecting  the  external  genitals 
and  injecting  one  fluid  dram  of  a  5  per  cent,  solution  of  novocain. 
The  prostate  and  seminal  vesicles  also  should  be  investigated. 
Localized  patches  of  inflammation  are  treated  by  the  application  of 
silver  nitrate  (J 2  per  cent.),  either  through  the  urethroscope  or  by 
means  of  a  deep  urethral  syringe  (Fig.  487) ,  every  two  or  three  days. 
Irrigations  and  injections,  as  in  acute  gonorrhea,  also  are  useful. 
When  the  discharge  depends  upon  stricture,  or  some  complication 
like  prostatitis,  folliculitis,  etc.,  the  treatment  is  that  of  the  complica- 
tion. Even  in  the  absence  of  stricture,  the  passage  of  a  sound  once 
or  twice  a  week  is  beneficial,  in  that  it  is  a  form  of  massage  which 
expresses  from  the  follicles  any  retained  secretions.     Anti-gonococcal 


Fig.  487. — Keyes-Ultzman  syringe. 

serum  and  gonococcal  bacterin  have  been  employed  in  the  treatment 
of  gonorrhea  and  its  complications,  but  their  value  is  not  yet  deter- 
mined. The  dose  of  the  bacterin  varies,  according  to  different 
observers,  from  50  to  200  millions  dead  bacteria  every  third  to 
every  seventh  day. 

Urethrorrhea  is  a  slight  discharge  of  a  non-purulent  mucoid  fluid 
from  the  urethra,  most  marked  in  the  morning  and  after  straining  at 
stool,  and  due  to  hyperactivity  of  the  urethral  glands.  The  dis- 
charge stains  but  does  not  stiffen  linen.  The  causes  are  sexual  excess, 
masturbation,  ungratilied  sexual  desire,  and  like  conditions  which 
induce  urethral  congestion.  It  is  sometimes  accompanied  by  sexual 
neurasthenia  and  false  impotence.  The  treatment  is  tonics  and  re- 
moval of  the  cause. 

Folliculitis,  or  inflammation  of  one  of  the  urethral  follicles,  is 
caused  by  urethritis,  usually  of  gonorrheal  origin.  A  tender,  pain- 
ful, shot-like  swelling  may  be  felt  beneath  the  skin  along  the  floor 
of  the  urethra.  If  suppuration  occurs  (periurethral  abscess),  the 
abscess  may  discharge  into  the  urethra,  through  the  skin,  or  in  both 


890  MANUAL   OF   SURGERY 

directions,  thus  forming  a  urinary  fistula.  The  treatment  is  the 
application  of  ichthyol.  If  pus  forms,  it  may  be  evacuated  through 
the  urethra  by  means  of  a  line  knife  and  the  urethroscope,  or  exter- 
nally if  the  suppuration  is  diffuse  under  the  skin.  A  urinary 
fistula  which  refuses  to  heal  should  be  cauterized,  or  faiUng  in  this, 
closed  by  a  plastic  operation. 

Cowperitis,  or  inflammation  of  Cowper's  gland,  is  identical  in 
cause  and  symptoms  with  folliculitis,  except  that  retention  of  urine 
is  more  apt  to  occur,  an  abscess  may  break  into  the  rectum,  as  well 
as  into  the  urethra  or  externally,  and  the  swelling  is  in  the  perineum, 
where  it  is  felt  best  between  the  forefinger  passed  just  within  the 
anal  sphincter  and  the  thumb  applied  to  the  perineum.  If  pus  forms, 
it  should  be  evacuated  by  a  perineal  incision. 

Stricture  of  the  urethra,  or  narrowing  of  the  lumen  of  the  canal, 
may  be  inflammatory,  spasmodic,  or  organic. 

Inflammatory  stricture  is  due  to  inflammatory  swelling  of  the 
mucous  membrane,  which  in  itself  is  scarcely  ever  great  enough  to 
interfere  seriously  with  the  passage  of  urine,  but  which  may  cause 
acute  retention  if  engrafted  on  an  organic  stricture. 

Spasmodic  stricture  occurs  in  the  membranous  urethra  as  the 
result  of  a  spasmodic  contraction  of  the  compressor  urethrae.  The 
causes  are  organic  stricture,  particularly  after  exposure  to  cold  or 
after  drinking  alcohol;  operations  on  or  injuries  of  the  perineum, 
rectum,  or  spermatic  cord;  and  nervous  and  emotional  disturbances. 
Retention  due  to  spasmodic  stricture  is  treated  by  a  hot  sitz  bath 
and  an  opium  suppository,  and,  if  these  fail,  by  the  introduction  of  a 
large  catheter,  which,  if  pressed  gently  but  firmly  against  the  stric- 
ture, will,  after  a  time,  tire  the  muscle  and  slip  into  the  bladder. 

Organic  stricture  may  be  congenital  (see  "  Congenital  Malforma- 
tions of  the  Urethra")  or  acquired.  Acquired  organic  stricture  is 
due  to  cicatricial  contraction,  the  result  of  gonorrhea  or  other  form 
of  urethral  inflammation,  or  injury,  such  as  rupture  or  laceration  of 
the  urethra.  Strictures  may  be  single  or  multilple.  The  usual 
situation  of  gonorrheal  stricture  is  in  the  bulb,  of  traumatic  stricture 
in  the  membranous  urethra.  Stricture  of  the  prostatic  urethra  is 
extremely  rare.  According  to  its  shape  the  stricture  may  be  annular, 
bridle  (involving  only  a  portion  of  the  circumference) ,  tubular  (when 
very  long),  or  tortuous;  according  to  its  consistency,  fibrous,  soft, 
cartilaginous,  or  elastic  or  resilient  (rapidly  recontracts  after  dilata- 
tion) ;  and  according  to  the  degree  of  narrowing,  impermeable  (does 
not  permit  the  passage  of  urine)  or  impassable  (when  instruments 
cannot  be  introduced).     A  stricture  of  small  calibre  is  one  through 


GENITAT.    ORGANS 


891 


which  a  number  15  French  sound  cannot  be  passed,  a  stricture  of 
large  calibre  one  which  will  admit  a  larger  instrument. 

The  results  are  dilatation  of  the  urethra  behind  the  stricture,  with 
chronic  inflammation  and  sometimes  ulceration.  If  the  ulcer  extends 
deeply,  a  perineal  abscess  and  subsequently  perineal  fistula  develop; 
the  latter  are  treated  by  external  urethrotomy,  with  incision  or 
excision  of  the  tracts.  When  the  obstruction  becomes  complete 
the  urethra  may  give  way,  leading  to  extravasation  of  urine.  The 
bladder  hypertrophies  and  ultimately  becomes  inflamed  and  some- 
times ulcerated,  while  stone  may  form  owing  to  the  alkaline  changes 
in  the  urine.  In  some  cases  the  bladder  walls  are  stretched  and 
thinned  instead  of  thickened.  Hydronephrosis,  pyonephrosis,  and 
pyelonephritis  also  may  ensue. 


■08 


Fir,.   488. —  Buugic 


bMiilc. 


Fig.  489. — Conical. 
Fig.  490. — Olivary. 
Fig.  491. — Cylindrical. 


Fig.  492. — Mercier  double 
elbow  (bicoude). 


\_S.WTZ.V3:iMS 


Fig.  493. — Elbow  (coude). 
Figs.  488  to  493. — Flexible  catheters. 

The  principal  symptom  is  gradually  increasing  difficulty  in  urina- 
tion, the  stream  becoming  forked,  progressively  smaller,  and  dribbling 
at  the  end.  ^licturition  takes  more  and  more  time,  and  finally 
retention  occurs,  usually  as  the  result  of  spasm  or  congestion  following 
exposure  to  cold  or  an  alcohoHc  debauch.  Except  for  gleet,  gonor- 
rheal stricture  does  not,  as  a  rule,  make  itself  known  for  many  months 
after  the  original  attack  of  urethritis,  and  may  not  cause  serious 
trouble  until  after  the  lapse  of  years.  The  diagnosis  may  be  made 
with  the  urethroscope  or  the  bougie  a  boule  (Fig.  488) ;  occasionally 
the  induration  can  be  felt  through  the  skin.  If  the  largest  bougie 
which  the  meatus  admits  meets  wdth  obstruction,  there  is  a  stricture 
as  the  meatus  is  normally  the  narrowest  part  of  the  canal.  Smaller 
sizes  should  then  be  used  until  one  finally  passes.  The  exact  situa- 
tion of  the  stricture  may  be  determined  by  noting  the  depth  at  which 
a  large  sound  meets  with  obstruction,  and  by  the  catching  of  the 


892  MANUAL   OF    SURGERY 

bulb  of  a  smaller  instrument  upon  withdrawal.  The  patient  should 
be  recumbent  and  the  thighs  separated.  The  glans  should  be 
cleansed  with  bichlorid  of  mercury  solution,  then  with  sterile  water, 
the  hands  disinfected,  and  the  bougie  sterilized,  and  anointed  with 
lubrichondrin  or  sterile  oil.  Flexible  instruments  (Fig.  488  to  493) 
will  sometimes  pass  an  obstruction  if  a  screwing  motion  is  used. 
Non-flexible  (Fig.  494)  instruments  should  be  allowed  to  find  their 
own  way  along  the  urethra  without  the  use  of  force.  The  penis  is 
held  in  one  hand  and  the  instrument  manipulated  with  the  other. 
The  shank  of  the  instrument  is  held  near  the  skin  of  the  groin,  and 
the  end  introduced  into  the  meatus,  until  the  curve  disappears 
within  the  urethra.  The  handle  is  then  carried  across  the  abdomen, 
still  close  to  the  skin,  to  the  median  line,  the  penis  pulled  up  on  the 
instrument,  and  the  handle  raised  to  the  vertical  and  finally  depressed 
between  the  thighs.  The  pocketing  of  a  small  instrument  in  the 
lacuna  magna  may  be  prevented  by  carrying  the  point  along  the  floor 
of  the  urethra  as  far  as  the  perineum,  obstruction  at  the  opening  of 


Fig.  494. — Conical  steel  bougie. 


the  triangular  ligament  and  at  the  sinus  pocularis  by  carrying  the  point 
along  the  upper  wall  of  the  rest  of  the  urethra.  The  dangers  of  the 
introduction  of  an  instrument  into  the  urethra  are  shock,  when  the 
urethra  is  hypersensitive,  a  condition  which  may  be  prevented  by 
distending  the  urethra  with  a  5  per  cent,  solution  of  novocain; 
hemorrhage,  which  may  be  avoided  by  gentleness;  false  passages; 
and  septic  processes,  e.g.,  prostatitis,  epididymitis,  cystitis,  and 
urinary  fever. 

The  treatment  of  stricture  is  (i)  dilatation,  (2)  urethrotomy,  or 
(3)  urethrectomy.  i.  Dilatation  may  be  giadual,  rapid,  or  continu- 
ous. Gradual  dilatation  is  the  best  treatment  for  all  non-resilient 
strictures  through  which  an  instrument  can  be  passed,  and  is  appli- 
cable in  over  95  per  cent,  of  all  cases  of  stricture.  The  largest  sound 
which  the  stricture  will  admit  is  introduced  and  allowed  to  remain  a 
few  minutes;  this  is  repeated  twice  a  week  with  larger  instruments, 
until  the  stricture  is  as  large  as  the  meatus  (from  27  to  32  F.).  The 
patient  should  take  a  urinary  antiseptic  during  the  treatment,  and  in- 
strumentation should  always  be  suspended  if  there  is  much  irritation. 


GENITAL   ORGANS  8q3 

Rapid  dilihilioii  consists  in  the  introduction  of  larger  bougies,  one  after 
the  other,  at  the  same  sitting,  until  the  full  size  is  reached.  Continuous 
dilitation  is  useful  in  very  small  strictures.  The  patient  is  confined  to 
bed,  and  a  line  bougie  introduced  and  kept  in  place  for  a  day  or  two, 
when  it  will  be  found  that  a  larger  instrument  can  be  passed.  This 
is  continued  until  a  still  larger  instrument  can  be  passed,  when  gradual 
or  rapid  dilitation  may  be  substituted.  Filiform  bougies  (less 
than  I  mm.  in  diameter)  are  made  of  whalebone  and  used  for  the 
finest  strictures.  A  filiform  bougie  is  apt  to  enter  one  of  the  crypts 
in  the  urethra,  in  which  case  it  should  be  partly  withdrawn,  then 
pushed  onward  with  a  rotary  movement.  If  a  filiform  fails  to 
enter  a  stricture,  the  urethra  should  be  filled  with  these  fine  instru- 
ments, when  it  will  be  found  that  one  will  engage  in  the  orifice  of 
the  stricture ;  it  may  then  be  left  in  place  for  continuous  dilatation 
or  a  tunneled  sound  or  catheter  (Fig.  495)  may  be  slipped  over  it.  An 
expert  may  possibly  introduce  a  filiform  through  the  urethroscope. 
Another  procedure  is  to  inject  10  drops  of  a  5  per  cent,  novocain 


Fig.  495. — Filiform  bougie  threaded  on  a  Gouley  tunneled  catheter. 

solution  with  5  drops  of  adrenalin  chloride  (i  to  1000);  this  lessens 
spasm  and  inflammatory  swelling.  After  a  few  minutes  the  urethra 
is  distended  with  warm  olive  oil,  when  the  filiform  may  glide  through 
the  stricture.  Forcible  dilitation,  or  divulsion,  in  which  the  stricture 
is  torn  by  means  of  an  instrument  working  on  the  same  principle 
as  a  glove  stretcher,  is  not  recommended.  After  any  method  of 
dilatation  an  instrument  should  be  passed  at  first  once  a  week,  then 
at  increasing  intervals,  to  make  sure  there  is  no  recontraction. 

2.  Urethrotomy,  or  cutting  of  the  stricture,  may  be  employed 
in  cases  which  resist  dilatation.  Internal  urethrotomy  is  indicated 
in  very  dense  or  resilient  strictures  in  the  pendulous  urethra.  Stric- 
tures near  the  meatus  may  be  incised  with  a  blunt  pointed  bistoury 
(see  "  IMeatotomy ") ;  in  deeper  strictures  a  special  instrument  is 
required.  Civiale's  urethrotome  is  used  by  passing  it  through  the 
stricture,  protruding  the  blade  by  a  mechanism  in  the  handle,  and 
cutting  the  stricture,  from  behind  forwards,  on  the  roof  of  the  ure- 
thra if  in  the  bulb,  on  the  floor  if  in  the  penile  portion.     Maison- 


894  MANUAL   OF   SURGERY 

neuve's  urethrotome  cuts  from  before  backwards,  and  is  useful  when 
the  stricture  is  very  small,  as  a  filiform  bougie  screwed  to  its  end  acts 
as  a  guide  to  the  stricture.  The  operation  may  be  performed  under 
general  anesthesia,  or  after  distending  the  urethra  with  a  5  per  cent. 
solution  of  novocain.  The  urethra  is  irrigated  previous  to  operation, 
and  a  full  sized  bougie  subsequently  passed  twice  a  week,  until  the 
tendency  to  recontraction  is  overcome. 

External  urethrotomy  has  the  same  indications  as  internal  ure- 
throtomy, when  the  stricture  is  in  the  posterior  third  of  the  urethra, 
(a)    Syme's  operation  is  performed  by  introducing  a  shouldered 


Fig.  496. — Syme's  staff. 

grooved  staff  (Fig.  496)  into  the  bladder,  and  opening  the  urethra 
just  behind  the  shoulder  of  the  staff,  which  corresponds  to  the  stric- 
ture, by  a  median  perineal  incision.  The  stricture  is  then  divided, 
and  a  large  catheter  passed  into  the  bladder  through  the  urethra, 
and  fixed  there  by  adhesive  plaster,  running  from  the  catheter  to  the 
penis.  The  perineal  w^ound  is  drained.  The  catheter  is  w-ashed 
daily,  and  removed  at  the  end  of  a  week,  after  which  sounds  are 
passed  twice  a  week,  the  perineal  wound  gradually  closing. 

(b)  Wheelhouse's  operationis  indicated  in  impassable  strictures. 
A  Wheelhouse  staff  (Fig.  497)  is  passed  down  to  the  stricture,  the 

" 


Fig.  497. ^Wheelhouse's  staff. 

urethra  opened  just  in  front  of  the  stricture  by  a  median  perineal 
incision,  and  a  probe  gorget  (Fig.  498)  pushed  through  the  opening 
and  the  stricture  divided.  The  after  treatment  is  that  of  Syme's 
operation. 

(c)  Cock's  operation  is  performed,  without  a  guide,  for  the  relief 
of  retention  of  urine  (Fig.  499).  The  left  index  finger  is  passed  into 
the  rectum  to  the  apex  of  the  prostate,  and  the  urethra  opened  be- 
hind the  stricture  by  a  median  perineal  incision.  The  stricture  may 
be  divided  at  the  same  time,  or  the  bladder  may  be  drained  through 
the  perineum,  and  the  stricture  dealt  with  at  a  later  period.  Far 
preferable  to  perineal  section  without  a  guide,  in  cases  in  which  there 


GENITAL   ORGANS 


^95 


is  no  extravasation  of  urine,  is  suprapubic  drainage,  after  a  few  days 
of  which  the  stricture  may  again  become  passable. 

3.  Urethrectomy,  or  excision  of  the  stricture  with  subsequent 
suture  of  the  urethra,  has  been  successfully  performed.  After 
the  removal  of  a  long  segment  of  the  urethra,  the  appendix  has  been 
transplanted  to  the  defect,  with,  it  is  said,  a  good  result.  Free 
venous  transplantation  has  always  ended  in  sloughing  of  the  trans- 
plant (see  hypospadias). 


Fig.  498. — Teale's  probe  gorget. 

False  passages,  or  channels  in  the  submucous  or  periurethral 
tissues,  may  result  from  attempts  to  introduce  an  instrument  into 
the  bladder.  The  instrument  lurches  onward  with  a  grating  sensa- 
tion, is  deflected  from  the  middle  line,  and  the  point  cannot  be  ro- 
tated as  it  should  be  if  it  had  entered  the  bladder.  No  urine  flows 
unless  the  instrument  reenters  the  urethra  or  bladder  behind!  the 
obstruction,  and  there  are  pain  and  hemorrhage.  No  evil  results 
may  follow,  but  in  some  cases 
there  will  be  urinary  fever  or 
extra  vasation  of  urine  and  blood. 
The  treatment  is  expectant  if  the 
patient  can  pass  urine.  If  there 
is  acute  retention  of  urine  and  the 
stricture  is  impassable,  suprapubic 
drainage  may  be  instituted,  unless 
there  is  leakage  of  urine  into  the 
perineal  tissues,  in  which  case  ex- 
ternal urethrotomy  will  be  manda-  ^'^c-  499— Cock's  operation. 
tory.  If  an  old  false  passage  interferes  with  catheterization,  it  may 
be  filled  with  filiform  bougies,  when  an  additional  filiform  will  pass 
into  the  bladder. 

Urinary,  urethral,  or  catheter  fever  may  be  acute  or  chronic.  The 
acute  form  quickly  follows  the  introduction  of  an  instrument,  and  is 
characterized  by  a  chill  with  a  subsequent  rise  of  temperature.  It  is 
of  nervous  or  possibly  septic  origin,  and  subsides  promptly  with  the 
use  of  opium,  quinin,  and  urinary  antiseptics.     The  chronic  form 


896  MANUAL    OF    SURGERY 

is  always  due  to  infection,  and  usually  begins  several  days  after  the 
introduction  of  an  instrument.  The  symptoms  are  those  of  septi- 
cemia, with  in  the  later  stages  those  of  uremia.  The  pathological 
findings  are  those  of  cystitis  and  pyelonephritis.  The  treatment 
is  first  prevention,  i.e.,  the  strictest  antiseptic  precautions  and  the 
greatest  gentleness  during  instrumentation.  When  once  developed 
the  condition  is  treated  on  the  same  principles  as  septicemia  and 
uremia,  with  urinary  antiseptics,  frequent  irrigations  of  the  bladder, 
and  in  some  cases  drainage  by  permanent  catheterization,  cystotomy 
or  nephrotomy. 

Injuries  of  the  penis  may  be  of  any  variety,  but  are  of  compara- 
tively infrequent  occurrence. 

Open  wounds  are  treated  on  general  principles.  The  bleeding 
owing  to  the  great  vascularity  of  the  part,  is  often  copious.  If  the 
urethra  is  opened  it  should  be  sutured  and  a  retention  catheter  in- 
serted. The  possible  sequelae  are  stricture  of  the  urethra  and  de- 
formity of  the  penis  from  cicatricial  contraction,  and  urinary  fistula. 
If  a  portion  or  the  whole  of  the  penis  has  been  cut  or  torn  away  the 
wound  should  be  treated  as  described  under  amputation  of  the  penis. 
Extensive  destruction  of  the  skin  alone  may  be  remedied  by  skin 
grafting. 

Subcutaneous  injuries  are  usually  the  result  of  forcible  bending  of 
the  penis  during  erection.  In  the  milder  cases  nothing  more  serious 
than  the  formation  of  a  hematoma  occurs.  In  the  so-called  frac- 
ture of  the  penis  (Fig.  484)  the  whole  organ  and  the  scrotum  become 
greatly  swollen  from  infiltration  of  blood  and,  if  the  urethra  is  torn, 
from  extravasation  of  urine.  The  subsequent  scar  formation  may 
cause  deviation  of  the  penis  during  erection.  The  treatment  of 
hematoma  and  urinary  extravasation  are  described  elsewhere. 

Strangulation  of  the  penis  from  the  constriction  of  cords,  rings,  etc., 
produces  great  swelling  and  eventually  gangrene.  The  urethra  is 
closed  and  extravasation  of  urine  may  follow,  leading  to  the  formation 
of  urinary  fistulae.  The  constricting  agent  must  be  removed,  with 
scissors,  bone  forceps,  or  file,  according  to  its  nature,  and  the  pro- 
phylactic treatment  for  gangrene  applied.  If  sloughs  form  they 
should  be  cut  away  with  scissors,  the  resulting  raw  area  being  sub- 
sequently skin  grafted. 

Chancroid,  or  soft  chancre,  is  a  non-syphilitic  sore  acquired  dur- 
ing coitus,  and  caused  by  the  bacillus  of  Ducrey.  The  period  of  incu- 
bation is  from  one  to  five  days.  Chancroids  are  usually  found  on  the 
glans,  the  prepuce,  or  the  labia,  and  very  rarely  in  any  extragenital 
situation.     A  soft  chancre  first  appears  as  a  red  papule,  which  quickly 


GENITAL    ORGANS  897 

changes  to  a  vesicle,  then  a  pustule,  and  hnally  a  painful  ulcer  with 
sharp  undermined  edges  and  a  yellowish  base,  which  secretes  a 
large  quantity  of  highly  contagious  pus.  As  a  rule  there  is  more  than 
one  ulcer,  the  pus  being  autoinoculable,  and  the  surrounding  parts  are 
inflamed.  The  inguinal  lymph  glands  are  very  apt  to  suppurate 
{soft  bubo) .  but  the  infection  never  becomes  generalized.  If  neglected 
or  if  occurring  in  those  with  poor  resistance,  chancroid  may  spread, 
with  or  withe ut  sloughing,  and  cause  great  destruction  of  tissue 
(phagedena).  The  differential  diagnosis  between  chancre,  chan- 
croid, and  herpes  is  given  under  "Chancre."  The  treatment 
is  spraying  with  peroxide  of  hydrogen,  washing  with  bichlorid  ot 
mercury  i  to  i.ooo,  and  dusting  the  sore  with  iodoform  or  thymol 
iodid.  Healing  usually  takes  place  within  two  or  three  weeks. 
Cauterization  with  the  actual  cautery  under  nitrous  oxide  anesthe- 
sia, or  with  carbolic  acid  after  the  application  of  10  percent,  novo- 
cain, is  strongly  recommended  by  seme  genito  urinary  surgeons, 
but  should  not  be  used  if  the  sore  is  near  the  meatus.  Phagedena 
is  treated  as  described  under  "Ulceration,"  while  the  bubo  is  dealt 
with  in  the  same  way  as  other  forms  of  adenitis.  If  phimosis  exists 
and  interferes  with  cleanliness,  the  prepuce  may  be  split  along  the 
dorsum,  and  the  raw  edges  touched  with  carbolic  acid;  circumcision 
is  generally  inadvisable,  as  the  entire  wound  is  apt  to  become  infected. 

Venereal  warts  are  papillomatous  masses  which  appear  on  the 
genitals  as  the  result  of  irritating  discharges  or  uncleanliness,  and 
occasionally  spontaneously,  hence  the  term  venereal  is  a  misnomer. 
They  may  be  snipped  oJBf  w4th  scissors  and  the  raw  surfaces  cauter- 
ized with  silver  nitrate. 

Phimosis,  or  stenosis  of  the  oritice  of  a  long  prepuce,  is  usually 
congenital  in  origin,  but  occasionally  results  from  cicatricial  contrac- 
tion. It  interferes  with  cleanliness,  thus  predisposing  to  local 
inflammatory  disorders,  and  later  in  Hfe  to  venereal  disease  and 
epithelioma;  adhesions  may  form  between  the  glans  and  the  prepuce, 
causing  retention  of  smegma  or  the  formation  of  preputial  stones. 
When  of  extreme  grade  it  interferes  with  urination,  thus  causing 
straining  and  predisposing  to  hernia  and  prolapsus  ani.  Retention 
of  urine  occasionally  occurs,  and  irritabihty  of  the  bladder,  mastur- 
bation, and  reflex  nervous  disorders  may  be  induced.  The  treatment 
is  circumcision,  which  may  be  performed  by  splitting  the  prepuce 
up  the  dorsum,  separating  adhesions,  trimming  the  flaps  flush  with 
the  corona  glandis,  and  suturing  the  skin  to  the  mucous  membrane 
with  catgut.  The  wound  is  dressed  with  vaselim'zed  gauze,  which 
should  be  changed  as  often  as  soiled.     When  circumcision  forceps 


898  MANUAL   OF   SURGERY 

are  used,  adhesions  are  first  separated  with  a  probe,  the  foreskin 
drawn  down,  and  the  forceps  applied  parallel  with  the  corona,  care 
being  taken  not  to  include  the  glans.  The  prepuce  is  then  amputated 
just  beyond  the  forceps,  and  sutures  applied  after  the  forceps  have 
been  removed. 

Paraphimosis  is  the  condition  existing  when  a  narrowed  preputial 
orifice  is  pushed  back  over  the  glans  and  cannot  be  replaced.  The 
parts  are  edematous,  sometimes  ulcerate  at  the  point  of  constric- 
tion, and  occasionally  become  gangrenous  distal  to  the  constriction. 
The  treatment  is  reduction  by  encircling  the  penis  behind  the  con- 
striction with  the  separated  index  and  middle  fingers  of  each  hand  and 
making  pressure  on  the  glans  with  both  thumbs,  a  maneuver  which 
presses  the  blood  from  the  glans  and  pulls  the  foreskin  down  over 
it  (Fig.  500).  Reduction  may  be  facilitated  by  multiple  punctures 
to  relieve  the  edema,  by  anointing  the  parts  with  sweet  oil,  and  by 


Pig.    500. — Method  of  reducing  paraphimosis.      (Hirsch.) 

general  anesthesia.  When  reduction  is  impossible,  the  constricting 
band  may  be  divided  on  the  dorsum  of  the  penis. 

Balanitis,  or  inflammation  of  the  glans,  is  usually  associated  with 
posthitis,  or  inflammation  of  the  prepuce  {balan posthitis).  The  con- 
dition is  favored  by  phimosis,  and  is  usually  the  result  of  uncleanli- 
ness,  or  other  forms  of  irritation,  such  as  chancroid,  gonorrhea,  and 
diabetes.  The  prepuce  is  edematous  and  a  purulent  discharge  es- 
capes from  its  orifice.  The  prepuce  may  ulcerate  and  the  inguinal 
glands  are  often  enlarged  and  tender.  The  treatment  is  frequent 
washings  with  peroxide  of  hydrogen  and  bichlorid  of  mercury  i 
to  5,000,  the  glans  being  separated  from  the  foreskin,  between  the 
washings,  by  lint  moistened  with  the  bichlorid  solution.  When 
the  prepuce  cannot  be  retracted,  it  will  often  be  necessary  to  split 
it  up  the  dorsum,  after  which  cleanliness  may  be  maintained. 

Epithelioma  of  the  penis  (Fig.  501)  usually  begins  close  to  the 


GENITAL   ORGANS 


899 


corona  glandis,  most  frequently  in  those  with  long  foreskins,  hence 
it  may  be  concealed  for  a  time,  the  only  evidence  of  its  existence  being 
some  swelling  and  a  discharge  containing  blood  and  pus.  The 
growth  has  the  usual  characteristics  of  cancer  elsewhere,  and  early 
implicates  the  inguinal  glands.  The  treatment  is  amputation  of  tJic 
penis  and  removal  of  the  inguinal  glands.  \\  hen  the  disease  is 
localized  to  the  distal  end,  the  section  may  be  made  through  the  body 
of  the  penis.  The  skin  flap  may  be  circular,  or  a  long  dorsal  and  a 
short  ventral  llaj)  may  be  employed.  The  corpus  spongiosum  is 
cut  a  little  longer  than  the  corpora  cavernosa,  and  the  end  of  the 
urethra  sutured  to  the  edges  of  the  flaps,  after  being  spHt  to  avoid 
stricture.     The  dorsal  arteries  of  the  penis  and  the  arteries  of  the 


Fig.   501. — Epithelioma  of  penis. 

corpora  cavernosa  will  require  ligation.  Extirpation  of  the  penis 
may  be  required  if  the  disease  is  more  extensive.  With  the  patient 
in  the  lithotomy  position,  the  root  of  the  penis  is  encircled  by  an 
incision  which  is  carried  downward  along  the  median  raphe  of  the 
scrotum  to  the  perineum.  The  divided  scrotum  is  separated,  and 
the  corpus  spongiosum  severed  in  front  of  the  triangular  ligament,  a 
catheter  having  been  passed  down  to  this  point  as  a  guide.  The 
suspensory  ligament  is  then  divided,  and  the  crura  severed  close  to 
the  bone.  The  end  of  the  urethra  is  split,  and  sutured  to  the  posterior 
angle  of  the  perineal  incision,  and  the  rest  of  the  wound  is  closed, 
with  ample  provision  for  drainage. 

Priapism  is  continuous  erection  of  the  penis,  without  sexual  de- 
sire or  seminal  emissions.     The  causes  are  local  irritation  from  phi- 


900  MANUAL   OF   SURGERY 

mosis,  adherent  prepuce,  diabetic  urine,  venereal  warts,  herpes, 
vesical  or  prostatic  stone,  stricture,  cystitis,  urethritis  fchordee), 
prostatitis,  sexual  excesses,  canthardal  poisoning,  distended  blad- 
der, or  diseases  of  the  rectum  and  anus;  interference  with  the  venous 
circulation  of  the  penis  from  scars,  tumors,  thrombosis,  hematomata; 
injuries  of  the  spinal  cord,  myeHtis,  spinal  meningitis,  lesions  of  the 
pons  or  middle  lobe  of  the  cerebellum,  epilepsy,  hydrophobia 
tetanus,  and  leukemia.  The  symptoms  are  pain  and  sometimes  diffi- 
culty in  urination  in  cases  depending  upon  lesions  of  the  central 
nervous  system,  however,  there  may  be  merely  turgescence  without 
pain.  The  treatment,  aside  from  that  of  the  underlying  cause, 
is,  when  pain  and  rigdity  are  present,  hot  or  cold  applications  and 
the  administration  of  nervous  sedatives  (bromids,  chloral,  opium, 
belladonna,  lupuHn,  hyoscin).  Incision  and  drainage  of  one  or 
both  corpora  cavernosa,  and  ligation  of  the  dorsal  arteries  of  the  penis 
have  been  advised.  Incision  is  particularly  indicated  in  the  pres- 
ence of  a  hematoma. 

Involuntary  seminal  emissions  during  sleep  {nocturnal  pollu- 
tions) occur  normally  in  the  cehbate,  at  intervals  varying  from  one 
week  to  a  month  or  longer,  according  to  the  temperament,  mode  of 
life,  and  direction  of  thought  of  the  individual.  Excessive  pollu- 
tions may  be  the  cause  or  the  result  of  neurasthenia;  they  may  be 
caused  also  by  masturbation  or  sexual  intemperance,  local  irritations 
of  various  sorts  (see  priapism),  highly  acid  urine,  and  most  frequently 
by  the  youthful  imagination.  Treatment  is  needed  only  when  the 
losses  recur  with  great  frequency,  when  they  are  associated  with 
mental  or  physical  suffering,  when  they  proceed  from  or  lead  to  atonic 
impotence,  or  when  on  the  shghtest  provocation  they  occur  during 
the  day  {diurnal  pollutions).  The  cause  should,  when  possible 
be  removed,  the  bowels  regulated,  and  the  general  health  improved. 
As  sleeping  on  the  back  predisposes  to  erections,  a  towel  may,  be- 
fore retiring,  be  tied  around  the  waist  with  the  knot  behind.  The 
most  useful  drugs  are  the  bromides,  hyoscin,  and  lupulin.  Lewd 
companions  and  novels,  erotic  plays  and  pictures  must  be  shunned, 
and  the  thoughts  diverted  from  sexual  affairs  by  some  useful  and 
absorbing  occupation. 

True  spermatorrhea,  i.e.,  a  constant  escape  of  semen  from  the 
urethra,  probably  does  not  exist,  most  of  the  cases  which  have  been 
so  diagnosticated  being  instances  of  uretorrhea  or  prostatorrhea  in 
which  the  discharge  has,  at  the  time  of  examination,  contained 
spermatozoa  as  the  result  of  a  previous  emission,  or  the  pressure  of 
fecal  masses  upon  the  seminal  vesicles  during  defecation. 


GENITAL   ORGANS  9OI 

Impotence,  or  inability  to  perform  the  sexual  act,  is  usually,  but 
not  always,  associated  with  sterility,  since  in  some  cases  there  rhay 
be  ejaculations  of  normal  semen.  Clinically  the  cases  may  be  divided 
into  two  groups: 

(i)  Organic  impotence  is  due  to  absence,  deformity  (e.g.,  epispa- 
dias, h^'pospadias,  penile  curvature  from  cicatricial  contraction), 
or  disease  of  the  genital  organs,  especially  atrophy  of  the  testes 
and  chronic  affections  of  the  prostate,  prostatic  urethra,  and  seminal 
vesicles;  to  lesions  of  the  spinal  cord,  notably  locomotor  ataxia  and 
myelitis;  to  hypopituitarism  or  hypothyroidism;  or  to  huge  tumors 
about  the  genitals,  elephantiasis  of  the  scrotum,  enormous, 
hernias  and  similar  conditions  that  interfere  mechanically  with  sexual 
intercourse. 

(2)  Functional  impotence  may  be  atonic  or  psychic.  Atonic 
impotence  is  caused  by  depression  or  exhaustion  of  the  nervous  centers 
as  the  result  of  debilitating  general  diseases,  the  prolonged  use  of 
certain  drugs  (e.g.,  alcohol,  arsenic,  bromides,  chloral,  cocain,  cam- 
phor, opium),  sexual  excesses  or  frequent  masturbation,  or  as  the 
result  of  repeated  and  protracted  episodes  of  sexual  excitement  with- 
out gratification  (mental  masturbation).  In  these  cases  sexual 
desire  and  erections  may  be  absent,  or  the  desire  may  be  strong  and 
the  erections  feeble,  the  emissions  occurring  prematurely  and  being 
followed  by  immediate  subsidence  of  the  erection.  The  diagnosis  of 
atonic  impotence  should  be  made  only  after  careful  investigation, 
as  in  many  instances  in  which  no  gross  lesion  can  be  discovered 
there  exists  an  old  gonorrheal  inflammation  in  the  prostatic  urethra 
or  seminal  vesicles.  Further,  excessive  venery  may  in  itself  induce 
chronic  inflammatory  changes  in  these  parts,  and  it  is  asserted  that 
oxaluria  and  other  irritating  conditions  of  the  urine,  as  well  as  diseases 
of  the  rectum  and  anus,  may  induce  precipitate  ejaculations.  Psy- 
chic impotence  is  most  common  in  the  newly  married,  as  the  result 
of  anxiety  as  to  their  ability  to  perform  the  marital  functions.  In 
other  cases  it  may  depend  upon  lack  of  affinity,  disgust,  or  similar 
emotions. 

The  treatment  consists,  when  possible,  in  removing  the  cause. 
Pituitary  extract  is  indicated  in  hypopituitarism,  thyroid  extract 
in  hypothyroidism.  Prolonged  sexual  rest  (including  avoidance 
of  obscene  books,  pictures,  and  plays),  regulation  of  the  bowels, 
improvement  of  the  general  health,  cold  baths,  electricity,  and  drugs 
like  strychnin,  phosphorus,  and  damiana  are  of  the  most  benefit  in 
atonic  cases.  In  psychic  impotence  depending  upon  fear,  reassur- 
ance is  the  principal  remedy.     Often  the  patient  is  convinced,  as 


902  MANUAL   OF    SURGERY 

the  result  of  reading  the  exaggerated  statements  of  charlatans,  that 
early  self-abuse  is  the  cause  of  his  misfortune.  He  must  be  told  the 
truth,  viz,  that  such  practice,  unless  carried  to  excess  over  a  long 
period,  is  not  followed  by  evil  consequences. 

Sterility,  or  inability  to  beget  children,  is  not  confined  to  the 
impotent,  it  may  occur  in  those  who  are  able  to  copulate  normally, 
in  which  event  it  is  the  result  of  aspermia  or  azoospermia  (see  also 
"Sterility  in  the  Female").  Aspermia  means  that  no  semen  is 
ejaculated  during  orgasm.  It  usually  depends  upon  obstruction  to 
some  portion  of  the  seminal  tract,  which  obstruction  may  be  congen- 
ital or  the  result  of  injury  or  disease,  most  commonly  stricture  of  the 
urethra,  enlarged  prostate,  or  obliteration  of  the  ejaculatory  ducts 
or  vasa  deferentia  from  gonorrheal  inflammation.  Wheii  the  semen 
passes  back  into  the  bladder  because  of  stricture  of  the  urethra,  or 
escapes  through  a  defect  in  the  urethra  the  result  of  epispadias, 
hypospadias,  or  urinary  fistula,  the  condition  is  sometimes  called 
false  aspermia,  or  malemission.  Azoospermia,  or  absence  of  sperma- 
tozoa from  the  semen,  is  due  to  absence,  malformation,  or  disease 
of  both  testicles,  or  to  obliteration  of  the  seminal  ducts,  the  most 
frequent  cause  being  bilateral  gonorrheal  epididymitis.  Repeated 
exposures  to  the  X-ray  also  may  cause  the  spermatozoa  to  disappear 
from  the  semen.  The  diagnosis  of  azoospermia  is  made  by  micro- 
scopic examination  of  the  semen. 

The  treatment  of  sterility  depending  upon  remedial  lesions,  e.g., 
stricture  of  the  urethra,  urinary  fistula,  is  that  of  the  cause.  Most 
cases  of  obstruction  to  the  seminal  ducts  are  beyond  the  aid  of  sur- 
gery, although  Martin  has  succeeded  in  curing  sterility  due  to  bilateral 
epididymitis  by  anastomosing  the  vas  deferens  to  that  portion  of 
the  epididymis  on  the  testicular  side  of  the  obstruction.  Sterility 
due  to  the  X-rays  may  dissappear  after  the  exposures  have  been 
discontinued. 

TESTIS,  CORD,  AND  SEMINAL  VESICLES 

The  testicle  may  be  absent  (anorchism),  fused  with  its  fellow 
(synorchism) ,  undescended  (cryptorchism),  out  of  place  (ectopia),  or 
inverted  in  the  scrotum,  while  at  least  one  case  of  supernumerary 
testis  (polyorcJiism)  has  been  reported. 

Undescended  testicle  (cry^/orc/zmw)  may  be  caused  by  "an 
unusual  length  of  the  mesorchium,  which  permits  so  free  a  movement 
of  the.  organ  that  it  fails  to  enter  the  mouth  of  the  vaginal  process, 
or  the  mesorchium  becomes  adherent  to  adjacent  structures;  the 


GENITAL   ORGANS  903 

abnormal  persistence  of  the  plica  vascularis;  certain  malformations 
of  the  testicle  and  its  component  parts,  such  as  a  short  vas  deferens 
and  an  abnormally  large  epididymis;  certain  forms  of  hermaphrodit- 
ism; retraction  of  the  cremaster  and  absence  of  the  internal  fibers 
of  the  cremaster  before  the  testicle  has  entered  the  inguinal  canal; 
want  of  development  of  the  inguinal  canal,  of  the  superficial  ab- 
dominal ring,  and  of  the  scrotum;  and  other  rare  causes,  such  as  the 
wearing  of  a  truss"  (Eccels).  The  organ  may  be  retained  within 
"the  abdomen,  in  the  inguinal  canal,  or  just  outside  of  the  external 
ring.  An  ectopic  testicle  may  be  found  in  the  peiineum,  Scarpa's 
triangle,  at  the  root  of  the  penis,  or  upon  the  aponeurosis  of  the 
external  oblique.  It  is  pulled  into  one  of  these  positions  by  the 
gubernaculum  or  pushed  there  by  a  hernia.  Imperfectly  descended 
and  misplaced  testicles  are  almost  always  small  and  soft  and  do  not 
produce  spermatozoa.  They  are  often  subject  to  attacks  of  in- 
flammation and  may  undergo  cystic  or  malignant  degeneration, 
while  hydrocele  and  hernia  (cf.  "Interstitial  Hernia")  are  frequent 
complications,  and  gangrene  maybe  induced  by  torsion  of  the  sperma- 
tic cord.  An  imperfectly  descended  testicle  must  not  be  mistaken 
for  a  bubo,  a  hernia,  or  a  hydrocele  of  the  cord.  In  abdominal  in- 
flammations and  tumors  in  the  male  the  scrotum  should  always  be 
examined  to  see  if  it  is  empty. 

Treatment  by  massage  is  dangerous  because  of  the  irritation 
which  it  produces.  If  the  organ  has  not  descended  by  the  sixth  year, 
the  best  treatment  is  Sevan's  operation.  The  inguinal  canal  is 
opened  as  in  Bassini's  operation,  and  the  peritoneal  pouch  separated 
from  the  cord  and  divided  between  two  ligatures,  thus  blocking  the 
hernial  sac  and  forming  a  tunica  vaginaHs.  The  cord  is  lengthened 
by  separating  it  from  the  surrounding  tissues  and  peritoneum,  and 
by  separating  the  vas  from  the  spermatic  vessels.  If  this  does  not 
produce  sufficient  lengthening,  the  spermatic  vessels  are  tigated  and 
divided,  the  testicle  generally  being  amply  nourished  by  the  arter>' 
of  the  vas,  although  the  author  has  had  two  cases  in  which  the  testicle 
subsequentl}^  became  gangrenous.  A  pocket  is  then  made  in  the 
scrotum  by  the  fingers,  the  testicle  placed  therein,  and  the  mouth  of 
the  pocket  closed  by  a  purse-string  suture.  The  wound  is  closed 
as  in  Bassini's  operation,  except  that  the  cord  is  not  displaced,  but 
allowed  to  emerge  at  the  lower  angle  of  the  wound.  Castration  is 
advised  by  many  surgeons,  but  should  never  be  done  if  the  condition 
is  bilateral,  for  though  sterile,  the  patient  may  be  potent,  and  removal 
of  both  organs  has  a  serious  effect  upon  development,  owing  to  the 
absence  of  the  internal  secretion  of  the  testicle. 


904 


MANUAL   OF   SURGERY 


Torsion  of  the  spermatic  cord  may  occur  during  severe  exertion 
if  there  is  a  long  mesorchium.  In  about  half  the  cases  the  testicle  is 
imperfectly  descended.  The  symptoms  resemble  strangulated  hernia 
in  that  there  are  sudden  pain,  swelling,  tenderness,  and  vomiting, 
but,  unlike  strangulated  hernia,  there  is  apt  to  be  fever  and  no  intes- 
tinal obstruction.  In  some  cases  the  twisting  of  the  cord  and  the 
rotation  of  the  testicle  may  be  made  out  by  palpation.  In  the  severe 
forms  the  testicle  becomes  gangrenous.  The  treatment  in  recent 
cases  is  exploratory  incision,  with  untwisting  of  the  cord  and  suturing 
the  testicle  to  the  scrotum.  A  gangrenous  testicle  should  be 
removed. 

Acute  orchitis,  or  inflammation  of  the  secreting  part  of  the  testicle, 
is  usually  due  to  hematogenous  infection,  e.g.  in  mumps,  t}^hoid 
fever,  and  less  frequently  in  other  infectious  diseases;  it  may  result 
also  from  injury  or  be  secondary  to  epididymitis.  The  symptoms 
are   sickening  pain   extending  upward   along  the  cord    and    often 


Pig.  502. — Diagrammatic  sections  of  (A) 
orchitis,  (B)  epididymitis,  and  (C)  hydrocele 
of  the  tunica  vaginalis.  Ho,  Testis,  A'',  epididy- 
mis; Hy,  hydrocele.      (Tillmanns.) 


Pig.     503. — Adhesive  plaster 
strapping  for  testicle.    (Heath.) 


to  the  loin;  great  tenderness,  uniform  sweUing  of  the  testicle, 
fever,  redness  and  edema  of  the  scrotum,  and  often  acute  hydro- 
cele. Atrophy  commonly  follows,  but  abscess  and  gangrene  are 
rare.  Since  in  right-sided  orchitis  or  epididymitis  there  may  be 
pain  and  tenderness  in  the  right  ihac  fossa,  with  vomiting,  acute 
appendicitis  may  be  simulated,  especially  if  the  testicular  trouble  is 
concealed,  as  it  sometimes  is  when  a  youth  is  examined  in  the  presence 
of  his  family. 

Acute  epididymitis  may,  in  rare  instances,  be  due  to  the  same 
causes  as  orchitis,  but  is  abnost  always  the  result  of  infection  spread- 
ing from  the  deep  urethra,  usually  arising  from  gonorrhea,  and  oc- 
casionally from  prostatitis,  the  passage  of  instruments,  or  other  forms 
of  irritation.  The  process  often  extends  to  the  testicle.  The 
symptoms  usually  arise  in  the  latter  stages  of  gonorrhea  and  are  those 
of  orchitis,  but  the  character  of  the  swelling  is  somewhat  different 
(Fig.  502),  the  vas  is  generally  swollen  and  tender,  and  on  rectal 


GENITAL   ORGANS  905 

examination  swellinfj;  and  tenderness  of  the  corresponding  seminal 
vesicle  and  lobe  of  the  prostate  can  often  be  detected.  Acute  hydro- 
cele is  common,  abscess  and  gangrene  rare.  In  bilateral  cases  there 
may  be  sterility  from  blocking  of  the  ducts,  but  sexual  potency  is 
retained  unless  the  testicle  atrophies,  which  is  not  usual. 

Chronic  orchitis  and  epididymitis  may  follow  the  acute  form; 
those  cases  which  are  chronic  from  the  beginning  are  generally  due 
to  syphilis  or  tuberculosis. 

The  treatment  of  acute  orchitis  or  epididymitis  is  rest  in  bed, 
elevation  of  the  scrotum,  the  application  of  lead-water  and  laudanum 
or  pultices,  and,  in  the  decUning  stages,  pressure  by  a  rubber  band- 
age or  by  strapping  the  testicle  with  adhesive  plaster  (Fig.  503). 
Local  treatment  to  the  urethra  is  abandoned ;  this  does  not  worry  the 
patient  as  the  discharge  has  probably  disappeared  with  the  onset  of 
the  inflammation.  In  acute  orchitis  with  excessive  pain  or  threat- 
ened gangrene,  the  tunica  albuginea  may  be  cut  subcutaneously  with 
a  tenotome.  In  acute  epididymitis  Frayser  advises  epididymotomy 
through  an  external  incision,  whereby  it  is  said  the  duration  of  the 
disease  is  considerably  shortened.  Recurring  epididymitis  has  been 
successfully  treated  by  ligation  of  the  vas  deferens  (Chetwood). 
Chronic  inflammation  of  the  testicle  is  treated  by  strapping,  or  by 
inunctions  of  ichthyol  and  mercury  and  the  internal  administration 
of  potassium  iodid. 

Tuberculosis  of  the  epididymis  and  testicle  usually  begins  in  the 
globus  major  of  the  epididymis,  as  the  result  of  a  deposition  of  the 
tubercle  bacilli  from  the  blood,  or  a  descending  infection  from  the 
seminal  vesicles  or  prostate.  As  in  other  affections  of  the  epididymis 
and  testicle  the  left  side  is  more  frequently  involved  owing  to  its  more 
sluggish  circulation.  The  disease  is  most  common  between  the 
fifteenth  and  thirtieth  years,  in  those  who  are  predisposed  to  tubercu- 
losis, and  it  is  often  preceded  by  inflammation  or  a  slight  injury. 
The  process  spreads  to  the  body  of  the  testicle  and  up  the  vas  deferens, 
affecting  the  other  genitourinary  organs,  including  in  many  cases 
the  opposite  epididymis  and  testicle.  In  favorable  cases  the  tuber- 
culous mass  may  become  encapsulated  and  calcify,  but  more  often 
it  undergoes  caseation,  and  forms  an  abscess,  which,  breaking  through 
the  capsule  of  the  epididymis,  gravitates  to  the  lower  postero-lateral 
corner  of  the  scrotum,  and  gives  rise  to  a  sinus. 

The  symptoms  may  be  acute,  resembling  an  acute  epididymitis 
which  fails  to  subside  and  is  followed  by  abscesses.  As  a  rule  the 
onset  is  insidious,  and  perhaps  the  nodular  enlargement  of  the  epidi- 
dymis is  discovered  accidentally.     At  a  later  period  the  whole  organ 


9o6 


MANUAL   OF   SURGERY 


is  enlarged,  effusion  into  the  tunica  vaginalis  is  apt  to  occur,  the  vas 
deferens  is  thickened  and  knotty,  and  finally  symptoms  referable  to 
the  other  genitourinary  organs  appear,  while  evidences  of  the  disease 
in  the  lungs  may  be  detected.  Pain  and  tenderness  are  not  marked 
until  sinuses  of  the  scrotum  form.  The  sexual  power  is  unimpaired 
unless  both  organs  are  destroyed.  The  differential  diagnosis  is 
given  under  "Tumors  of  the  Testicle." 

The  treatment  is  the  wearing  of  a  suspensory,  and  general  treat- 
ment as  for  tuberculosis  elsewhere.  Injections  of  iodoform  or 
zinc  sulphate  are  not  recommended.  If  the  disease  progresses, 
epididymectomy  should  be  performed,  with  removal  of  the  vas  if  it 
is  thickened;  this  operation  does  not  cause  atrophy  of  the  testicle  or 


Fig.   504. — ^Fungus  of  testicle  following  gumma. 

impotency.  When  the  testicle  is  extensively  diseased,  castration 
should  be  performed  when  the  process  is  unilateral;  when  bilateral, 
the  worse  testicle  should  be  removed,  and  at  least  a  portion  of  the 
other  preserved.  Tuberculosis  in  other  portions  of  the  genitourinary 
apparatus  sometimes  subsides  after  removal  of  the  testicular  foci, 
and  should  not.  therefore,  be  attacked  at  the  same  time. 

Syphilis  of  the  testicle  during  the  secondary  period  appears  as  a 
bilateral,  painless  epididymitis,  affecting  principally  the  globus  major; 
it  is  sometimes  associated  with  hydrocele,  and  disappears  with  anti- 
syphilitic  treatment.  During  the  tertiary  period  syphilitic  orchitis, 
or  sarcocele,  occurs  as  a  diffuse  overgrowth  of  the  connective  tisues, 
causing  atrophy  of  the  tubules,  or  as  a  nodular,  gummy  degeneration. 
The  symptoms  appear  slowly.     The  testicle  is  enlarged,  hard,  smooth 


GENITAL   ORGANS  907 

or  perhaps  nodular,  unduly  heavy  for  its  size,  and  neither  painful  nor 
tender;  hydrocele  may  occur,  and  if  a  gumma  oi)enson  the  surface, 
it  will  present  the  characteristic  features  of  a  syphilitic  ulcer.  The 
treatment  is  a  suspensory  bandage  and  the  internal  administration  of 
antisyphilitic  remedies.  If  the  testicle  is  extensively  destroyed  by 
ulceration,  however,  castration  should  be  performed. 

Hernia,  or  fungus  of  the  testicle,  is  a  protrusion  of  the  interior  of 
the  testicle  or  a  fungus  growth  therefrom,  through  the  skin  of  the 
scrotum  (Fig.  504).  It  may  be  due  to  a  wound,  malignant  disease, 
abscess,  syphilis,  or  tuberculosis.  The  treatment  is  that  of  the  cause. 
In  cases  following  abscess  or  trauma,  the  fungus  may  be  cauterized 
and  pressure  applied,  or  amputated  and  the  skin  sutured  over  the 
stump. 

Tumors  of  the  testicle  are  usually  malignant  and  of  a  mixed 
type.  The  most  common  non-malignant  tumor  is  cystic  fibroma,  or 
adenoma,  which  consists  of  fibrous  tissue  with  multiple  serous 
cysts;  it  may,  however,  contain  other  forms  of  tissue  and  in  the 
later  stages  is  apt  to  become  malignant  Dermoid,  teratoma,  chon- 
droma, osteoma,  fibroma  and  myxoma  also  have  been  observed.  Of 
the  malignant  tumors  sarcoma  is  the  more  frequent,  carcinoma 
is  almost  always  of  the  medullary  variety.  Malignant  disease  may 
be  secondary  to  benign  tumors  and  is  often  cystic  in  character. 
Both  sarcoma  and  carcinoma  spread  along  the  cord,  invade  the  lumbar 
glands,  break  through  the  scrotum, and  then  involve  the  inguinal 
glands. 

The  diagnosis  of  the  exact  nature  of  a  neoplasm  of  the  testicle 
is  seldom  possible  before  exploratory  incision.  The  chnician  is 
usually  content  to  distinguish  a  neoplasm  from  other  lesions  not 
requiring  castration.  If  this  distinction  cannot  be  made  by  external 
examination  an  exploratory  incision  should  be  made.  Rarely  an 
acute  orchitis  may  be  simulated  by  a  rapidly  growing  neoplasm, 
with  pain,  tenderness,  increased  local  heat,  and  fever.  A  hydrocele 
with  thick  walls,  which  prevent  the  transmission  of  light,  is  very 
chronic-,  increases  slowly  in  size,  and  may  yield  hydrocele  fluid  on 
tapping.  An  old  hematocele  that  has  become  organized  is  heavy, 
regular  in  form,  and  remains  stationary  or  decreases  in  size.  As 
with  tumor,  it  may  follow  injury  and  yield  blood  on  aspiration.  In 
both  vaginal  hydrocele  and  hematocele  the  cord  is  uninvolved. 
Excluding  the  conditions  just  mentioned  a  tumor  of  the  testicle 
is  most  likely  to  be  confused  with  chronic  epididymitis,  tuberculosis, 
or  sarcocele.  The  following  table  modified  from  Keyes,  shows  the 
main  points  in  the  diagnosis  of  these  diseases. 


9o8 


MANUAL   Of   SURGERY 


Chronic 
Epididymitis 

Tuberculosis 

Syphilitic 
orchitis 

Tumor 

Gonorrhea,  strict- 
ure,    or     hyper- 
trophy    of    pro- 
state. 

Tuberculosis  , 
family     or     per- 
sonal. 

Syphilis  inherited 
or  acquired. 

Perhaps  trauma. 

Frequency 

Uncommon. 

Frequent. 

Frequent. 

Rare. 

Size 

Small   between 
[attacks. 

Does     not     reach 
any  great  size. 

Does     not     reach 
any  great  size. 

May     reach     any 

size. 

Tenderness 

Yes. 

Not  marked  until 
sinus  forms. 

No. 

No. 

Between     attacks 
testis  normal, 
nodules  often   in 
globus  minor. 

Nodules  in  globus 
major  in  the  be- 
ginning.     Testis 
not  involved  un- 
less acute  or  an- 
cient. 

Testis  evenly  en- 
larged,     slightly 
nodular,  epididy- 
mis usually  free. 

Testis   greatly  en- 

larged. Later  ir- 
regular soft  out- 
growths. No  char- 
acteristic involve- 
ment of  epididy- 
mis. 

Cord 

May    be    slightly 
thickened. 

Thick  and  nodu- 
lar. 

Free. 

Free  in  early  stage. 

Later  involved. 

Seminal  vesicles... 

Usually  distended. 

Tuberculous. 

Uninfluenced. 

Uninfluenced. 

Prostate 

Posterior    urethra 
inflamed. 

Congested   or   tu- 
berculous. 

Uninfluenced. 

Uninfluenced. 

Cloudy. 

Cloudy,  may  con- 
tain bacilli. 

Clear. 

Clear. 

Hydrocele 

Unusual. 

Often. 

Nearly  always. 

Unusual,  but 
possible. 

Onset 

Usually  acute. 

Usually  chronic. 

Chronic. 

Chronic. 

Age 

Adult  life. 

Not     often     after 
30. 

Middle  life. 

Any  age. 

Epididymis. 

Epididymis. 

Testicle. 

Testicle. 

Recurring      acute 
attacks. 

Chronic. 

Very  chronic. 

Usually  rapid. 

Suppuration 

Unusual. 

Common.       Sinus 
lower  postero- 
lateral corner 
scrotum. 

Rare.         Anterior 
or  lateral  fungus 
possible. 

None,  but  fungus 
common  in  later 
stages. 

Atrophy  of  testis. . 

Rare,  potency  un- 
impaired. 

Rare,    potency 
somewhat        im- 
paired. 

Common,  potency 
somewhat        im- 
paired. 

Never,  potency  un- 
impaired. 

Opposite  testicle. . 

Often  involved  si- 
multaneously. 

Usually    involved 
subsequently. 

Usually  free.              Free. 

1 

Malignant  disease  is  the  only  condition  likely  to  cause  enlarge- 
ment of  the  iliac,  lumbar,  and  inguinal  glands.  The  aspirator  and 
antisyphilitic  remedies  may  be  of  value  in  diagnosis,  also  the  labora- 


GENITAL   ORGANS  909 

tory  tests  for  syphilis,  gonorrhea,  and  tuberculosis.  The  X-ray 
might  reveal  a  dermoid,  teratoma,  chondroma,  osteoma,  or,  in 
tuberculosis  or  an  old  hydrocele,  areas  of  calcitication. 

The  treatment  of  tumors  of  the  testicle  is  castration. 

Castration  is  best  performed  through  an  incision  over  the  external 
inguinal  ring.  The  cord  is  isolated,  crushed  with  forceps,  tied  en 
masse,  severed  below  the  ligature,  and  each  vessel  secured  by  an 
individual  ligature.  The  testicle  is  next  pushed  up  through  the 
wound  stripped  from  the  scrotum,  and  removed,  any  bleeding 
points  being  ligated.  This  incision  may  be  modified  to  include 
sinuses  or  diseased  skin.  When  the  operation  is  done  for  tuberculosis, 
the  inguinal  canal  should  be  opened,  and  the  vas  followed  until  it 
may  be  tied  and  cauterized  close  to  the  seminal  vesicle.  In  malig- 
nant disease  the  vessels  should  be  secured  as  high  as  possible,  and  any 
accessible  lymph  glands  removed.  If  the  scrotum  is  invaded,  the 
inguinal  glands  should  be  excised  whether  they  are  enlarged  or 
not. 

Neuralgia  of  the  testicle  may  be  caused  by  ungratified  sexual 
desire,  sexual  irregularities,  incipient  inguinal  hernia,  or  by  some 
local  or  remote  disease,  e.g.,  varicocele,  prostatic  engorgement,  and 
vesical  or  renal  calculus.     The  treatment  is  removal  of  the  cause. 

Hydrocele  is  a  collection  of  serous  fluid  in  the  tunica  vaginaUs, 
or  in  connection  with  the  cord  or  testicle.  Vaginal  hydrocele  (Fig. 
505),  or  a  collection  of  fluid  in  the  tunica  vaginalis,  may  be  sympto- 
matic or  idiopathic.  Symptomatic  hydrocele  {serous  vaginalitis)  is 
often  acute  may  be  caused  by  injury  or  any  disease  of  the  testicle 
or  epididymis,  and  sometimes  follows  operation  for  inguinal  hernia. 
Idiopathic  hydrocele  is  always  chronic,  is  most  common  in  the  middle 
aged,  and  is  of  unknown  origin.  The  fluid  is  straw  colored,  and 
contains  albumin,  fibrinogen,  inorganic  salts,  often  cholesterin 
crystals,  and  occasionally  fibrous  bodies  containing  phosphates, 
carbonates,  and  fibrin.  The  tunica  vaginalis,  in  old  cases,  becomes 
thickened  and  fibrous,  or  even  cartilaginous  or  calcified.  Warty 
growths  may  arise  from  the  tunic  or  the  testicle. 

The  signs  of  a  vaginal  hydrocele  are  a  tense,  pear-shaped, 
fluctuating  swelling,  which  grows  from  below  upward,  and  which  is 
usually  situated  in  front  of  the  testicle,  but  occasionally  lies  behind 
or  envelops  this  organ. "  It  is  flat  on  percussion,  and  has  no  impulse 
on  coughing  unless  it  extends  into  the  inguinal  canal.  By  placing 
a  Ught  on  one  side  of  the  swelling,  translucency  will  be  demonstrated, 
unless  the  tunica  vaginalis  is  very  thick  or  the  fluid  bloody  or  mucoid. 
The  situation  of  the  testicle  may  be  determined  by  the  light  test, 


gio 


MANUAL    OF    SURGERY 


and  by  the  peculiar  sensation  experienced  by  the  patient  when  the 
organ  is  squeezed. 

The  treatment  may  be  palUative  or  radical.  Palliative  treatment 
consists  in  tapping,  the  needle  being  entered  at  the  front  and  lower 
part  of  the  swelling.  The  position  of  the  testicle  should  always  be 
ascertained  just  before  the  operation.  After  the  fluid  has  been 
withdrawn  the  puncture  should  be  sealed  with  collodion.  Tapping  is 
often  curative  in  children,  and  sometimes  in  symptomatic  hydrocele, 
but  practically  never  in  the  idiopathic  variety,  the  sac  refilling  after 
the  lapse  of  a  few  months.  Radical  treatment  may  be  carried  out 
by  injection  or  by  an  open  operation.  Of  the  many  substances 
recommended  for  injection  pure  carbohc  acid  is  the  best,  from  lo  m. 
to  a  dram  being  injected  into  the  sac  and  diffused,  by  manipulation 


Fig.  505.  Fig.  506.  Fig.  507.  Fig.  508.  Fig.  509. 

Vaginal  Congenital  Infantile  Bilocular  Encysted  hydro- 

hydrocele.  hydrocele.  hydrocele.  hydrocele.  cele  of  cord. 

Diagram  of  various  forms  of  hydrocele.      H,  hydrocele;  T,  testicle;  E,  epididymis;  F, 

funicular  process;  C,  cord. 

after  all  the  fluid  has  been  withdrawn.  There  is  some  inflammatory 
reaction,  and  retapping  may  be  necessary  if  there  is  much  effusion. 
Open  operation  possesses  the  advantage  of  allowing  inspection  of  the 
testicle,  and  is  always  indicated  if  the  sac  is  thickened.  The  patient's 
permission  to  deal  with  any  testicular  lesion  which  may  be  present 
should  always  be  obtained,  particularly  if  the  hydrocele  has  formed 
rapidly.  Open  operation  may  be  by  incision,  excision,  or  eversion 
of  the  sac.  Incision  of  the  sac,  followed  by  packing  it  with  iodoform 
gauze,  should  be  obsolete.  Excision  consists  in  removing  the  entire 
parietal  layer  of  the  tunica  vaginalis.  It  is  indicated  in  cases  in 
which  the  wall  of  the  sac  is  very  thick.  Eversion  of  the  sac  is  the  best 
operation,  when  the  sac  wall  is  thin.  The  sac  is  opened  by  a  small 
incision,  turned  inside  out,  and  so  held  by  a  few  catgut  sutures 
passed  through  its  edges  above  the  testicle  and  behind  the  cord. 


GENITAL   ORGANS  QII 

The  testicle  is  then  replaced  within  the  scrotum  and  the  wound 
closed. 

Congenital  or  reducible  hydrocele  (Fig.  506)  is  one  which 
communicates  with  the  peritoneal  cavity  through  an  unclosed 
funicular  process,  hence  is  associated  with  hernia,  the  treatment 
is  that  of  congenital  inguinal  hernia.  Injections  should  never  be 
used. 

Infantile  hydrocele  (Fig.  507)  is  one  which  distends  the  tunica 
vaginalis  and  the  funicular  process,  the  latter,  however,  not  communi- 
cating with  the  peritoneal  cavity.  The  treatment  is  tapping,  the 
walls  of  the  sac  being  scratched  with  the  end  of  the  needle.  If  this 
fails  the  sac  should  be  excised  or  everted. 

Bilocular  abdominal  hydrocele  (Fig.  508)  is  an  infantile  hydro- 
cele in  which  the  upper  end  of  the  funicular  process,  distended  with 
fluid,  lies  between  the  peritoneum  and  the  abdominal  wall.  The 
treatment  is  excision. 

Inguinal  hydrocele  is  one  about  a  retained  testicle;  it  is  dealt 
with  by  excision  or  eversion,  and  the  organ  brought  down  into  the 
scrotum. 

Encysted  hydrocele  of  the  testis  is  a  cyst,  or  collection  of  cysts, 
occuring  in  or  about  the  epididymis  {Cysts  of  the  epididymis)  or 
rarely  in  the  testicle.  There  are  two  varieties :  (i)  Small  cysts  occur 
late  in  life;  contain  spermatozoa,  and  cause  little  or  no  disturbance; 
they  are  said  to  be  due  to  senile  changes  causing  a  dilatation  of  the 
tubules.  (2)  Large  cysts  occur  before  middle  age  and  contain  a 
milky  fluid  filled  with  spermatozoa  {spermatocele) ;  they  are  due  to 
dilatation  of  the  vasa  elTerentia,  or  to  cystic  changes  in  persisting 
fetal  remains,  being  in  this  respect  similar  to  parovarian  cysts.  The 
treatment  is  injection  or  excision. 

Diffuse  hydrocele  of  the  cord  is  a  smooth  boggy  enlargement  of 
the  cord,  which  may  be  due  to  edema,  spermatocele,  multilocular 
encysted  hydrocele  of  the  cord,  lymphangioma,  cysts  of  fetal  remains, 
or  echinococcus  cysts.     The  treatment,  excepting  edema,  is  excision. 

Encysted  hydrocele  of  the  cord  (Fig.  509)  is  due  to  distention 
of  the  funicular  process  which  has  been  closed  for  a  variable  distance 
above  and  below,  or  rarely  to  an  accumulation  of  fluid  in  an  old 
hernial  sac  which  has  been  shut  off  above.  In  the  female  the  canal 
of  Xuck  may  be  likewise  affected,  constituting  a  hydrocele  of  the 
round  ligament.  The  condition  may  be  mistaken  for  hernia,  owing 
to  the  fact  that  it  may  enter  the  inguinal  canal,  but  if  the  cord  is 
drawn  dow^nwards.  the  cyst  is  fixed,  and  presents  the  features  of  a 
hydrocele  elsewhere.     The  treatment  is  injection  or,  better,  excision. 


912  MANUAL   OF   SURGERY 

Chylocele,  or  chylous  hydrocele,  is  a  collection  of  lymph  in  the 
tunica  vaginalis,  due  to  the  rupture  of  dilated  lymph  vessels,  and 
often  associated  with  hlariasis.  The  treatment  is  that  of  hematocele, 
with  possibly  ligation  or  excision  of  the  dilated  lymph  vessels. 

Hematocele  is  a  collection  of  blood  in  or  about  the  testicle  or  cord. 
It  follows  injury  or  operations,  and  occasionally  occurs  spontaneously, 
e.g.,  in  mahgnant  disease  and  hemophilia.  According  to  its  situa- 
tion it  may  be  a  vaginal  hematocele,  i.e.,  in  the  tunica  vaginahs,  an 
encysted  or  diffuse  hematocele  of  the  cord,  or  an  encysted  hematocele  of 
the  testicle.  The  signs  are  those  of  hydrocele,  except  that  the  swell- 
ing is  doughy  or  solid,  and  not  translucent,  and  there  is  apt  to  be 
ecchymosis  of  the  skin.  An  old  hematocele  that  has  become  organ- 
ized may  be  mistaken  for  a  neoplasm,  (cf.  Diagnosis,  of  Tumors 
of  the  Testicle).  The  treatment  is  rest  and  the  application  of  cold,  or 
in  the  presence  of  continued  bleeding,  incision  and  ligation  or  pack- 
ing. In  old  cases  in  which  the  blood  has  not  been  absorbed,  incision 
and  evacuation  may  be  indicated. 

Rupture  of  the  vas  deferens,  as  the  result  of  operations  or  injuries, 
should  be  treated  by  anastomosis  in  a  manner  similar  to  anastomosis 
of  the  ureter. 

Varicocele  is  a  condition  in  which  the  veins  of  the  pampiniform 
plexus  are  dilated,  thickened,  and  tortuous.  It  is  very  common, 
and  is  most  frequent  in  young  men.  ■  It  is  almost  always  on  the  left 
side,  because  the  left  testicle  hangs  lower,  because  the  left  spermatic 
vein  opens  into  the  renal  vein  at  right  angles  and  has  no  valves, 
while  that  on  the  right  has  valves  and  opens  obhquely  into  the  vena 
cava,  and  because  the  left  vein  lies  behind  the  sigmoid  flexure  and  is 
apt  to  be  compressed  when  the  latter  is  distended.  The  cause  is 
said  to  be  unrelieved  sexual  desire.  It  may  be  due  also  to  the  pressure 
of  a  truss  or  an  abdominal  tumor,  and  is  then  usually  acute,  and 
occurs  on  either  side  at  any  time  of  life.  The  condition  is  readily 
recognized,  the  veins  feeling  Hke  a  "bag  of  earth  worms;"  it  has  a 
sHght  impulse  on  coughing,  disappears  on  lying  down,  and  refils 
from  below  upwards  if  pressure  is  made  over  the  external  ring  and 
the  patient  is  asked  to  stand.  The  symptoms,  when  they  exist, 
are  neuralgia  and  hypochondria.  The  treatment  is  the  use  of 
suspensory  bandage,  and  the  apphcation  of  cold  water  night  and 
morning.  There  is  no  danger  of  impotence.  Operation  is  indicated 
when  the  condition  is  the  source  of  constant  anxiety.  Our  plan  is  as 
follows:  The  inguinal  canal  is  opened  as  in  the  operat-on  for  hernia, 
the  testicle  pulled  up  into  the  wound,  and  the  veins  separated  from 
the  vas  and  its  vessels  and  excised,  the  cremaster  muscle  being 


GENITAT.    ORGANS  913 

shortened  if  the  cord  is  very  long.  Search  is  always  made  for  a  small 
hernial  sac,  which  may  be  responsible  for  the  "neuralgia."  As 
the  inguinal  canal  has  been  dilated  by  the  varicocle,  it  is  obliterated 
as  in  the  operation  for  hernia,  since  removal  of  the  veins  leaves  an 
open  canal.  The  subcutaneous  operation  and  injections  are  not 
recommended. 

Acute  seminal  vesiculitis  is  caused  by  posterior  urethritis,  usually 
gonorrheal  in  nature.  The  symptoms  are  pain  in  the  perineum, 
rectum,  hip,  or  back,  increased  by  urination  and  defecation;  frequent 
micturition;  and  sometimes  priapism  and  painful,  bloody  emissions. 
There  is  fever,  and  the  distended,  tender  vesicle  can  be  felt  by  rectal 
examination,  above  and  to  the  outer  side  of  the  prostate.  The 
treatment  is  that  of  acute  prostatitis.  If  suppuration  occurs,  the 
abscess  should  be  opened  through  the  perineum. 

Chronic  seminal  vesiculitis  follows  the  acute  form,  when  it 
constitutes  one  of  the  causes  of  gleet,  or  it  is  due  to  sexual  irregulari- 
ties or  prostatic  disease.  The  symptoms  are  those  of  the  acute  form, 
but  much  milder  in  degree.  There  is  sexual  feebleness  but  increased 
desire,  and  usually  marked  depression  of  the  spirits.  Recurring 
epididymitis  is  common.  We  have  seen  several  cases  in  which, 
because  of  backache  and  hematuria,  the  diagnosis  of  renal  calculus 
had  been  made.  Chronic  seminal  vesiculitis  has  been  held  responsi- 
ble for  many  chronic  joint  infections.  The  treatment  is  a  hot  rectal 
douche  daily,  and  massage  of  the  vesicles  once  a  week.  Massage  is 
performed  while  the  bladder  is  full  and  the  patient  bends  over  a  chair. 
A  finger  is  inserted  into  the  rectum  and  the  vesicles  gently  stripped 
from  above  downwards.  Autogenous  vaccins  are  recommended 
by  some  surgeons.  The  accompanying  neurasthenia  and  posterior 
urethritis  also  should  receive  attention.  In  inveterate  cases  collar- 
gol  (10  per  cent.)  may  be  injected  into  the  vesicles  by  inserting  the 
needle  into  each  vas  deferens  (vasopuncture),  the  vesicles  may  be 
opened  and  drained  (vesiculotomy)  through  the  perineum,  or  excised 
(vesiculectomy)  by  one  of  the  routes  mentioned  below. 

Tuberculosis  of  the  seminal  vesicle  may  be  primary,  or  sec- 
ondary to  the  same  disease  iti  the  prostate  or  epididymis,  the  symp- 
toms of  which  usually  bring  the  patient  to  the  surgeon.  On  rectal 
examination  the  vesicles  are  found  tender  and  dilated,  or  even 
nodular.  The  bacilli  may  occasionally  be  found  in  the  fluid  ex- 
pressed from  the  vesicles  by  massage.  The  treatment  includes  the 
general  measures  suitable  for  tuberculosis  elsewhere,  with  the  removal 
of  more  accessible  foci,  e.g.,  in  the  epididymis.  If  the  disease  con- 
tinues to  progress,  the  vesicles  may  be  removed  through  the  per- 


914  MANUAL    OF   SURGERY 

inciim.  by  the  transsacral  route  as  in  Kraske's  operation  on  the  rectum 
or  by  a  suprapubic  or  inguinal  incision,  through  which  the  vesicles 
are  reached  cxtraperitoneally.  The  dangers  of  veseculectomy  and 
vesiculotomy  are  injury  to  the  urethra,  bladder,  ureter,  rectum,  and 
peritoneum. 

PROSTATE  GLAND 

Acute  prostatitis  is  caused  by  posterior  urethritis,  usually  gonor- 
rheal in  nature,  but  occasionally  following  the  passage  of  instruments 
or  calcuH.  The  symptoms  are  frequent  micturition;  prostatic  shreds 
or  pus  in  the  urine;  pain,  tenderness,  heat,  and  weight  in  the  peri- 
neum, increased  by  defecation  and  urination;  chills  and  fever;  and 
sometimes  priapism,  hematuria,  or  retention  of  urine.  On  rectal 
examination  the  prostate  feels  hot.  swollen,  tender,  and.  if  suppura- 
tion has  occurred,  boggy  or  fluctuating.  A  prostatic  abscess  usually 
opens  into  the  urethra,  sometimes  into  the  rectum  or  through  the 
perineum,  and  rarely  into  the  bladder.  The  treatment  consists  of 
laxatives,  hot  rectal  douches,  opium  suppositories,  and  poultices  to 
the  perineum.  If  suppuration  occurs,  the  abscess  may  sometimes 
break  into  the  urethra  on  the  passage  of  a  catheter;  if  this  does  not 
occur,  or  if  the  abscess  is  large,  it  should  be  opened  by  a  median 
perineal  incision. 

Chronic  prostatitis  may  follow  the  acute  form,  but  is  usually 
chronic  from  the  beginning.  The  symptoms  are  enlargement  and 
tenderness  of  the  prostate,  pain  on  urination  and  defecation,  and  the 
discharge  from  the  urethra  of  a  thin,  milky  fluid  containing  prostatic 
casts  iprostatorrhca).  especially  after  defecation.  Prostatorrhea  may 
occur  also  without  prostatitis,  and  then  has  the  same  causes  and  the 
same  treatment  as  urethrorrhea.  In  some  of  these  cases  there  is 
atonic  impotence  and  frequent  nocturnal  emissions.  The  treatment 
is  tonics,  gentle  massage  of  the  prostate,  the  passage  of  a  large 
sound  twice  a  week,  and  instillations  of  a  few  drops  of  a  5  per  cent, 
solution  of  silver  nitrate  into  the  posterior  urethra.  Kot  rectal 
douches,  suppositories  of  ichthyol,  and  counterirritation  to  the 
perineum  also  have  been  recommended.  Should  an  abscess  form,  it 
is  treated  as  described  above. 

Tuberculosis  of  the  prostate  is  usually  secondary  to  that  of  the 
seminal  vesicles  and  epididymis.  The  prostate  becomes  nodular, 
and  later  suppuration  ensues.  The  symptoms  are  painful  and  fre- 
quent micturition,  hematuria,  pyuria,  and  pain  in  the  back  and  peri- 
neum. Tubercle  bacilh  may  be  found  in  the  urine.  The  treatment 
is  that  of  tuberculosis  elsewhere.     In  suitable  cases  the  prostate 


GENITAL   ORGANS 


915 


may  be  removed  throujiii  the  ])erineLini,  or  abscesses  opened,  curetted, 
and  jvuked  with  iodoform  gauze. 

Prostatic  calculi  are  caused  by  thede])ositionof  j)hosphatesorjn- 
spissated  prostatic  secretion.  They  may  cause  prostatitis,  abscess 
of  the  prostate,  or  retention  of  urine.  They  may  show  on  a  skia- 
gram, and  occasionally  they  may  be  felt  with  a  urethral  sound  or  by 
rectal  examination.  NVhen  producing  trouble,  they  should  be  re- 
moved by  a  median  j)erineal  section. 

Hypertrophy  of  the  prostate  is  a  senile  enlargement  of  the  gland, 
the  cause  of  which  is  not  known.  It  is  very  rare  before  fifty,  but  is 
said  to  be  present  in  one-third  of  all  men  who  have  reached  the 
sixtieth  year,  producing  symptoms,  however,  in  only  one-half  of 
these.  All  the  elements  of  the  gland  hypertrophy,  but,  according 
to  the  tissue  which  predominates, 
the  growth  may  be  hard  and  fibrous 
or  soft  and  adenomatous.  As  a 
rule  the  changes  are  more  marked 
in  certain  portions  of  the  gland, 
so  that  the  specimen  consists  of  a 
number  of  encapsulated  tumors, 
which  may  be  fibroadcnomatous  or 
adenofibromaious ,  depending  upon 
which  tissue  is  in  excess.  In  about 
20  per  cent,  of  those  removed  at 
operation  carcinomatous  elements        Fig.  510.— Hypertrophy  of  the  pros- 

nrp  found  ProQfntir  hvnprtrnnhv  ^^*®-  Note  retroprostatic  pouch  and 
are  lOUna.       Prostatic  nypertropny     residual  urine,  the  marked,  anterior  curve 

lengthens    the     prostatic     urethra,     and    increased    length    of    the    prostatic 
...  urethra. 

and  sometimes  gives  it  a  tortuous 

course,  owing  to  the  irregular  enlargement  of  different  portions  of  the 
gland.  The  outlet  of  the  bladder  is  always  elevated,  thus  creating 
a  pouch  behind  the  prostate  and  preventing  complete  evacuation  of 
the  bladder  (Fig.  510).  In  some  cases  the  commissure  between  the 
lateral  lobes  may  constitute  a  bar  across  the  urethra,  or  a  peduncu- 
lated growth,  the  so-called  third  lobe,  which  obstructs  the  internal 
urinary  meatus  like  a  ball-valve.  The  anterior  commissure  is  rarely 
involved. 

The  symptoms  are  frequent  urination,  especially  at  night,  and 
difficulty  in  urination.  The  stream  is  hard  to  start,  has  httle  force, 
and  is  terminated  by  dribbling.  The  difficulty  is  increased  rather 
than  lessened  by  straining,  which  may  be  so  great  as  to  cause  hema- 
turia, hernia,  or  prolapse  of  the  anus.  There  may  be  pain  and  a 
sense  of  fulness  in  the  perineum,  and  priapism  sometimes  occurs 


91 6  MANUAL   OF    SURGERY 

owing  to  the  congestion  about  the  neck  of  the  bladder.  These 
sjTnptoms  are  insidious  in  onset  and  gradually  grow  worse,  the 
residual  urine  progressively  increasing  in  amount.  At  this  period 
indulgence  in  alcohol  or  catching  cold  is  apt  to  increase  the  congestion 
and  lead  to  retention  of  urine,  which,  unless  reheved  by  the  catheter, 
results  in  overflow  (the  incontinence  of  retention).  The  patient 
may  have  several  of  these  attacks,  until  finally  the  bladder  remains 
full  all  the  time,  the  urine  constantly  dribbling  away.  The  bladder  is 
now  dilated,  atonic,  and  fasciculated,  and  the  back  pressure  of  the 
urine  leads  to  dilatation  of  the  ureters  and  of  the  pelves  of  the 
kidnej's.  Either  spontaneously  or  as  the  result  of  instrumentation 
the  bladder  and  prostate  become  inflamed,  and  the  urine  ammoniacal 
and  purulent,  the  patient  finally  dying  from  an  ascending  infection  of 
the  kidneys.  Phosphatic  vesical  calculi  may  form,  and  epidid\Tnitis 
may  occur,  particularly  after  the  passage  of  a  catheter.  The 
diagnosis  is  confirmed  by  rectal  examination,  which  is  greatly  fac- 
ilitated by  making  firm  pressure  over  the  h}'pogastrium  (bimanual 
examination),  the  bladder  being  empty,  the  legs  flexed,  and  the 
mouth  open.  The  finger  readih-  detects  the  enlarged  lateral  lobes  of 
the  gland.  In  about  20  per  cent,  of  the  cases  rectal  examination  is 
fallacious,  because  the  chief  enlargement  is  forwards  and  not  back- 
wards. In  these  cases  the  obstruction  at  the  neck  of  the  bladder  will 
be  appreciated  by  the  passage  of  a  catheter,  which  may  be  used  to 
ascertain  also  the  length  of  the  urethra  and  the  amount  of  residual 
urine,  i.e.,  the  quantity  of  urine  which  may  be  drawn  off  immediately 
after  the  patient  has  passed  water.  The  bladder  should  always  be 
searched  for  stones.  In  cases  in  which  it  can  be  used,  the  cystoscope 
may  be  employed  to  outline  accurately  the  nature  of  the  obstruction. 
The  X-ray  is  of  value,  not  only  for  the  detection  of  stones,  but  also, 
especially  if  the  bladder  is  distended  with  air,  for  showing  the  size 
of  a  hard  prostate.  "WTien  there  are  s}Tnptoms  of  prostatic  re- 
tention without  any  hypertrophy  of  the  prostate,  the  essential 
lesion  is  a  contracture  of  the  neck  of  the  Madder''^  (Keyes).  This  is 
usually  due  to  posterior  urethritis  and  is  curable  by  perineal 
cystotomy. 

The  treatment  in  the  early  stages  consists  in  attention  to  the 
general  health,  the  drinking  of  plenty  of  water,  and  the  avoidance  of 
cold,  wet,  alcohol,  and  overeating.  When  the  residual  urine 
amounts  to  two  ounces,  the  bladder  should  be  catheterized  every 
evening  before  retiring;  each  additional  two  ounces  of  residual 
urine  will  require  an  additional  catheterization,  the  intervals  always 
being  regular.     This  the  patient  must  be  taught  to  do  in  a  surgically 


GENITAL    ORGANS  917 

clean  maiiiuT,  laying  cmj)hasis  upon  the  ease  with  which  infection 
occurs,  and  the  great  dangers  which  follow.  Hexamethylenamine, 
grains  lo  three  times  a  day,  or  other  urinary  antiseptics  should  be 
administered,  and  the  bladder  irrigated  with  hot  boric  acid  solution 
once  daily.  If  the  ordinary  soft  catheter  cannot  be  passed,  and  this 
applies  equally  in  cases  of  acute  retention,  a  soft  coude  or  bicoude 
(Figs.  492  and  493)  catheter  may  mount  the  obstruction  and  enter 
the  bladder;  if  these  fail,  it  will  be  necessary  to  use  a  silver  prostatic 
catheter  (Fig.  511),  which,  owing  to  its  greater  length  and  larger 
curve,  may  reach  the  bladder  when  pressed  well  down  between  the 
thighs.  If  catheterization  is  difficult,  if  there  is  marked  irritability  of 
the  bladder,  if  the  residual  urine  steadily  increases  in  quantity,  or  if 
there  is  stone  or  persistent  cystitis,  catheterization  should  be  aban- 
doned and  operation  advised.  Seriously  damaged  kidneys  or  the 
presence  of  septicemia  is  an  indication  that  operation  has  been 
postponed  too  long. 


Prostatic  catheter. 


Prostatotomy,  or  incision  of  theprostate,  may  be  performed  with 
the  knife  or  the  cautery,  either  through  the  perineum,  or  after  the 
bladder  has  been  opened  above  the  pubes,  the  situation  of  the  cut 
varying  according  to  which  lobe  is  chiefly  enlarged;  but  these 
operations  are  seldom  employed.  Most  surgeons  think  prostatec- 
tomy, as  complete  as  possible,  to  be  the  operation  of  choice. 

Prostatectomy,  or  removal  of  the  prostate,  may  be  complete  or 
partial,  and  effected  either  through  the  perineum  (intra-  or  extra- 
vesically)  or  by  the  suprapubic  route.  The  mortaHty  is  from  5  to  10 
per  cent.,  but  the  vast  majority  of  those  who  recover  are  cured. 
The  operation  may  be  rendered  safer  by  estimating  the  functional 
capacity  of  the  kidneys  (q.v.) ;  performing  suprapubic  cystotomy^ 
under  local  anesthesia,  for  drainage;  and,  after  a  week,  or  when  the 
patient's  general  condition  has  improved  and  the  renal  activity  has 
been  restored  as  much  as  possible,  removing  the  prostate  under 
nitrous  oxid-oxygen  anesthesia.  Most  of  the  deaths  after  operation 
are  due  to  uremia,  pneumonia,  sepsis,  or  a  combination  of  these  evils. 


9l8  MANUAL   OF   SURGERY 

Among  the  sequelae  are  impotence,  incontinence  of  urine,  epididy- 
mitis, urinary  fistula,  rectal  fistula,  and  urethral  stricture. 

Suprapubic  prostatectomy  is  the  operation  generally  employed. 
It  is  performed  by  opening  the  bladder  as  in  suprapubic  cystotomy, 
tearing  through  the  mucous  membrane  over  the  prostate  with  the 
finger-nail  or  blunt  scissors,  and  enucleating  the  gland  by  working 
between  the  true  and  the  false  prostatic  capsules,  while  the  prostate 
is  pushed  upwards  by  a  finger  in  the  rectum.  If  the  lateral  lobes  are 
removed  separately,  the  ejaculatory  ducts  may  occasionally  be 
preserved.  The  hemorrhage  is  controlled  by  irrigation  with  hot 
water,  or  temporary  gauze  packing,  and  the  bladder  drained  as  after 
suprapubic  cystotomy.  The  operation  is  easy,  quick,  requires  no 
special  instruments,  permits  full  exploration  of  the  bladder,  does  not 
injure  the  rectum,  is  rarely  followed  by  a  permanent  fistula,  and  does 
not  always  destroy  the  sexual  function.  The  urine  begins  to  pass 
through  the  urethra  in  from  one  to  two  weeks,  and  the  suprapubic 
wound  is  healed  in  from  two  to  four  weeks. 

Perineal  prostatectomy  may  be  performed  through  a  curved 
transverse  incision,  convexity  forward,  reaching  from  one  ischial 
tuberosity  to  the  other,  or  one  of  its  modifications,  but  the  easiest 
and  simplest  is  the  median  incision  as  in  perineal  cystotomy.  The 
membranous  urethra  is  opened,  and  the  prostate  pulled  downwards 
by  a  sound  passed  into  the  bladder,  or  by  special  tractors  devised 
for  this  purpose,  and  enucleated  after  incising  its  fibrous  sheath.  The 
bladder  is  drained  by  a  tube  emerging  through  the  perineum,  and 
the  wound  packed  with  gauze.  The  drain  may  be  removed  in  a  few 
days,  the  after  treatment  being  the  same  as  that  of  perineal  cysto- 
tomy. Young  incises  the  capsule  outside  of  the  seminal  ducts,  in 
order  to  preserve  these  structures,  and  removes  the  rest  of  the  gland. 
Dittel,  Rydygier,  and  others  make  a  transverse  perineal  incision,  and 
excise  V-shaped  portions  of  the  lateral  lobes  without  opening  the 
urethra  or  bladder  (extravesical  prostatectomy) .  The  perineal  opera- 
tion is  more  difficulty  than  suprapubic  prostatectomy,  and  has  the 
special  danger  of  injury  to  the  rectum. 

If  the  symptoms  are  severe,  and  prostatectomy  cannot  be  prac- 
ticed because  of  the  poor  general  condition  of  the  patient,  the  only 
operation  which  promises  relief  is  CA-'stotomy,  either  suprapubic 
or  perineal,  for  the  purpose  of  drainage. 

Carcinoma  of  the  prostate,  as  previously  mentioned,  is  found  in 
about  20  per  cent,  of  the  glands  removed  for  supposed  benign  hyper- 
troph5^  Sarcoma  is  rare,  and  may  occur  in  early  life.  The  symp- 
toms of  carcinoma  are  much  like  those  of  hypertrophy  of  the  prostate, 


GKNITAL   ORGANS  QI9 

but  the  pain  is  greater,  the  growth  more  rai)i(l,  "hematuria  more 
common,  and  the  gland  stony  hard  and  nodular.  In  the  later  stages 
the  tumor  breaks  through  the  cai)sule,  invades  the  bladder,  urethra, 
and  rectum,  causes  metastases  in  the  pelvic  and  inguinal  lymphatic 
glands,  and  induces  cachexia.  The  treatment,  if  the  patient  is  seen 
early  enough,  is  removal  of  the  entire  prostate,  the  seminal  vesicles, 
and  the  anterior  two-thirds  of  the  trigone,  through  the  perineum, 
the  bladder  being  anastomosed  with  the  membranous  urethra. 
Young  has  performed  this  operation  six  times,  one  patient  being  well 
at  the  end  of  live  years.  When  excision  is  out  of  the  question,  some 
relief  may  be  obtained  by  suprapubic  cystotomy  and  radiotherapy. 

FEMALE  GENITAL  ORGANS 

Examination  of  the  female  generative  organs  is  [usually  made 
with  the  patient  in  the  dorsal  position,  the  knees  being  drawn'up  and 


Fig.  si 2. — Goodell's  speculum. 

the  thighs  abducted,  and  the  bladder  and  rectum  having  previously 
been  emptied.  The  external  genitals  should  first  be  inspected.  By 
separating  the  labia,  the  urethra,  the  hymen  or  its  remains,  and  the 
perineum  may  be  seen,  and  if  the  patient  strains,  a  cystocele  or 
rectocele  may  be  detected.  For  inspecting  the  inner  parts  a  specu- 
lum is  necessary,  the  most  serviceable  of  which  is  one  of  the  bivalve 
variety  (Fig.  512).  The  instrument  is  warmed  and  lubricated,  and 
introducecl  with  the  blades  closed  and  facing  laterally;  it  is  then 
turned  so  that  the  edges  are  lateral,  and  the  blades  separated.  The 
Sims  speculum  is  used  with  the  patient  in  the  Sims  position  (Fig.  513) , 
i.e.,  lying  upon  the  left  side,  with  the  left  arm  behind  the  back,  the 
right  shoulder  near  the  table,  and  the  hips  flexed,  the  right  more  than 
the  left.  The  speculum  is  introduced,  then  turned  transversely,  so 
as  to  retract  the  posterior  vaginal  wall,  the  right  buttock  being  lifted 
with  the  disengaged  hand.  The  cylindrical  speculum  of  Fergusson 
consisting  of  glass  or  hard  rubber,  and  having  the  inner  extremity 
beveled,  is  seldom  employed.  By  vaginal  palpatiou  may  be  deter- 
mined the  condition  of  the  perineum,  whether  or  not  the  vulvo- 


920 


MANUAL    OP    SURGERY 


vaginal  glands  are  enlarged,  the  presence  of  spasm  and  tenderness, 
the  amount  of  heat  and  moisture,  the  condition  of  the  vaginal  walls, 
the  presence  or  absence  of  tumors  or  masses,  and  the  size,  shape,  posi- 
tion, mobility,  and  consistency  of  the  cervix  and  uterus.  Either  the 
index,  or  the  index  and  middle  fingers,  according  to  whether  the 
patient  is  single  or  married,  are  lubricated  and  passed  into  the  vagina 
over  the  perineum;  by  placing  the  other  hand  over  the  lower  abdo- 


FiG.   513. — Sims'  position.      (Montgomery.) 

men  {bimanual  examination)  the  uterus,  tubes,  and  ovaries  may  be 
palpated  between  the  fingers  and  their  condition  determined.  The 
right  side  of  the  pelvis  is  best  examined  with  the  right  hand  internally, 
the  left  with  the  left  hand  internally.  In  virgins,  instead  of  a 
vaginal  examination,  and  always  in  others  as  supplemental  to  a  vaginal 
examination,  it  is  desirable  to  pass  a  finger  into  the  rectum  and 
examine  the  parts  bimanually.     This  examination  is  facilitated,  if 


Fig.   514. — Volsella  forceps. 

at  the  same  time  the  cervLx  is  drawn  downward  by  volsella  forceps 
(Fig.  514) .  In  order  to  determine  the  degree  of  prolapsus  uteri  some 
surgeons  examine  the  patient  in  the  erect  posture.  The  patient 
stands  with  the  legs  apart,  while  the  examiner,  kneeling  on  one 
knee  and  facing  the  patient,  passes  the  fingers  into  the  vagina,  sup- 
porting his  elbow  with  the  other  knee.  Before  or  after  the  internal 
examination  the  abdomen  should  always  be  examined  externally  by 


GENITAL    ORGANS  92 1 

inspection,  palpation,  and  percussion,  and  sometimes  by  ausculta- 
tion. When  these  examinations  are  unsatisfactory,  it  may  be 
necessary  to  anesthetize  the  patient  in  order  to  secure  complete 
relaxation.  The  uterine  sound  (Fig.  515)  may  be  used  to  determine 
the  length,  permeability,  and  direction  of  the  uterine  canal,  the 
presence  of  growths,  the  condition  of  the  endometrium,  and  occa- 
sionally to  replace  a  displaced  uterus.  It  is  seldom  employed,  how- 
ever, because  of  the  dangers  of  sepsis,  perforation,  or  abortion,  and 
it  is  absolutely  contraindicated  in  acute  inflammatory  troubles,  in 
cancer,  during  the  menstrual  period,  and  in  cases  in  which  there  is  the 
slightest  suspicion  of  pregnancy.  The  vagina  and  the  sound  should 
be  sterilized,  and  the  instrument,  properly  curved,  introduced  under 
the  guidance  of  the  eye,  the  position  of  the  uterus  having  been  pre- 


FiG.   515. — Sims'  uterine  sound. 

viously  determined.  The  interior  of  the  uterus  may  be  explored 
also  with  the  linger,  after  the  cervix  has  been  dilated,  or  a  portion 
of  the  endometrium  may  be  removed  with  a  curette  for  micro- 
scopic examination. 

THE  VULVA 

Any  or  all  parts  of  the  vulva  may  be  absent,  rudimentary,  or 
hyper trophied.  Enormous  hypertrophy  of  the  labia  minora  is  seen 
in  the  Hottentot  apron.  Epispadias  and  h}^pospadias  also  occur. 
Thus  hermaphrodism  (presence  of  both  ovaries  and  testicles)  does  not 
occur,  but  pseudohermaphrodism,  in  which  the  external  genitals 
resemble  those  of  both  sexes,  is  sometimes  seen. 

The  vulva  is  subject  to  the  same  diseases  and  injuries  as  other 
parts  covered  by  skin  and  mucous  membrane,  and  only  a  few  of 
these  need  special  description. 

Vulvitis  is  usually  gonorrheal  in  origin,  but  may  be  caused  by 
irritating  discharges,  uncleanliness,  diabetic  urine,  parasites,  infec- 
tious fevers,  traumatism,  caustics,  pregnancy,  and  excessive  mas- 
turbation or  coitus.  Follicular  vulvitis  is  acne.  Cellulitis  of  the 
vulva  is  called  phlegmonous  vulvitis.  During  the  acute  exanthemata 
or  other  debihtating  diseases  the  parts  may  become  gangrenous 
{gangrenous  vulvitis,  noma  pudendi),  or  covered  with  a  false  mem- 
brane {croupous  vulvitis);  true  diphtheria  also  occurs.     The  symp- 


92  2  MANUAL   OF   SURGERY 

toms  are  localized  pain  and  burning,  more  marked  on  walking  or 
during  micturition.  The  parts  are  swollen,  reddened,  and  covered 
with  a  mucopurulent  discharge.  The  treatment  is  removal  of  the 
cause,  and  cleanliness.  Rest  in  bed,  sitz  baths,  and  local  applica- 
tions of  the  medicaments  recommended  for  injection  in  gonorrhea 
are  indicated.  In  the  severer  forms  tonics  and  stimulants  are 
needed,  while  cellulitis  will  call  for  incision,  and  gangrene  for  excision 
and  cauterization. 

Abscess  of  the  vulvovaginal  or  Bartholin's  gland  is  caused  by 
vulvitis,  and  presents  the  usual  signs  of  an  abscess.  The  treatment 
is  incision,  or  excision  with  partial  closure  of  the  wound  and  drainage. 
A  cyst  of  the  vulvovaginal  gland  caused  by  occlusion  of  its  duct 
likewise  is  treated  by  excision. 

Pruritus  vulvae,  or  intense  itching  of  the  vulva,  is  a  symptom 
rather  than  a  disease,  and  may  be  caused  by  uncleanliness,  local 
skin  diseases,  irritating  discharges,  diabetic  urine,  parasites,  mas- 
turbation, rectal  diseases,  digestive  disorders,  gout  and  rheumatism, 
pregnancy,  the  menopause,  diseases  of  the  internal  generative  organs, 
and  kraurosis  vulvae.  The  itching  is  worse  after  exercise  and  at  night 
and  leads  to  excoriation  and  trophic  changes  in  the  skin;  melan- 
cholia sometimes  follows.  The  treatment  is  removal  of  the  cause, 
attention  to  the  general  health,  and  local  cleanliness.  The  itching 
may  be  relieved  by  lead-water  and  laudanum,  carbolic  solution 
(5  per  cent.),  cocain  (5  per  cent.),  by  painting  the  parts  with  silver 
nitrate  (10  grains  to  the  ounce)  and  sometimes  by  radiotherapy. 
Excision  of  the  affected  skin,  or  resection  of  the  nerves  supplying  it 
with  sensation  has  been  performed  in  inveterate  cases. 

Kraurosis  vulvae  is  an  atrophic  change  in  the  vulvar  skin  leading 
to  shrinking  and  thickening  of  the  parts,  which  become  white  and 
smooth.  The  cause  is  unknown,  and  the  symptoms  are  usually 
pruritus  and  sometimes  intense  hyperesthesia.  The  treatment  is 
that  of  pruritus. 

Urethral  caruncle  is  a  dark-red  tumor  growing  from  the  mucous 
membrane  in  or  near  the  urethral  meatus.  The  growth  is  a  papil- 
loma, angioma,  or  adenoma,  and  is  exceedingly  sensitive,  causing 
dysuria,  pain  on  walking  or  intercourse,  and  marked  nervous  symp- 
toms.    The  treatment  is  excision. 

THE  VAGINA 

The  vagina  may  be  double  owing  to  failure  of  union  of  the  lower 
portions  of  Miiller's  ducts,  lateral  if  one  of  the  ducts  fails  to  develop, 


GENITAL   ORGANS  923 

or  iihsciil  or  rudimentary,  in  whole  or  in  j)art  (sec  also  "Atresia  Ani 
X'aginalis''). 

Atresia  of  the  vagina  (complete  closure)  occurs  at  the  hymen 
{atresia  hymenal  is)  or  at  a  higher  level  {atresia  vaginalis).  It  may 
be  congenital,  or  be  caused  by  cicatricial  contraction  the  result  of 
traumatism,  operations,  caustics,  or  the  severer  forms  of  vaginitis. 
The  symptoms  are  caused  by  retention  of  menstrual  fluid.  At  the 
time  of  the  periods  there  are  all  the  symptoms  of  menstruation 
except  the  appearance  of  blood.  The  vagina  becomes  distended 
{hcmatoeolpos),  and  after  a  time  the  uterus  {/lematometra),  and  then 
the  tubes  {hematosalpinx).  When  the  distention  becomes  extreme, 
the  blood  may  burst  through  any  poition  of  the  genital  tract,  or 
through  the  atresia,  an  accident  which  is  often  followed  by  infection 
and  death. 

The  treatment  is  puncture  or  incision  of  the  obstruction,  in  order 
to  allow  the  blood,  which  may  be  as  thick  as  tar,  to  escape  slowly. 
The  opening  is  then  enlarged,  the  cavity  irrigated  with  a  mild 
antiseptic  solution,  and  the  opening  maintained  by  gauze,  or  by  a 
rubber  or  glass  plug.  If  the  tubes  are  distended,  they  are  probably 
adherent,  hence  collapse  of  the  uterus  and  vagina  often  results  in 
their  rupture  and  peritonitis;  the  condition  of  the  tubes  should 
therefore  be  investigated  before  operating  on  the  atresia,  and  if 
distended,  they  should  first  be  removed  by  abdominal  section.  In 
absence  or  obliteration  of  the  vagina  efforts  have  been  made  to 
construct  a  canal  by  flaps  from  the  labia,  by  skin  grafting,  by  the 
substitution  of  a  portion  of  the  rectum,  and  by  the  transplantation 
of  a  segment  of  the  small  intestine.  We  have  obtained  an  almost 
perfect  result  by  the  method  last  mentioned. 

Stenosis  of  the  vagina  (incomplete  closure)  results  from  the 
same  causes  as  atresia,  and  may  interfere  with  intercourse,  drainage 
of  the  vagina,  and  labor.  The  treatment  is  gradual  dilatation  with 
bougies,  or  a  plastic  operation. 

Injuries  of  the  vagina  may  be  caused  in  a  great  variety  of  ways, 
e.g.,  by  coitus,  bullets,  falls  astride  some  sharp  object,  and  rough 
instrumentation.  They  are  treated  on  general  surgical  principles. 
If  the  peritoneal  cavity  has  been  penetrated  by  some  pointed  object, 
the  abdomen  should  be  opened  in  order  to  search  for  wounds  of  the 
intestines.  By  far  the  most  frequent  and  important  injuries  are 
those  occurring  during  labor. 

Laceration  of  the  perineum  is  usually  caused  by  childbirth, 
rarely  by  external  injuries.  According  to  position  the  laceration 
mav  be  lateral,  the  fibers  of  the  levator  ani,  on  one  or  both  sides,  being 


924 


MANUAL   OF   SURGERY 


torn;  median;  or  central,  a  rare  form  in  which  the  child  is  born 
through  a  perforation  of  the  perineum,  the  vulva  remaining  intact. 
According  to  degree  the  laceration  may  be  incomplete  or  complete 
the  latter  passing  through  the  sphincter  ani.  Perineal  relaxation  is  a 
term  used  for  those  cases  in  which  there  has  been  a  submucous 
tear  of  the  levator  ani  fibers. 

The  symptoms  are  a  feeling  of  insecurity  in  the  parts,  dragging 
pain,  and  reflex  nervous  disorders.  Incomplete  median  tears  may 
give  no  symptoms.  When  the  levator  ani  is  torn,  the  anus  falls  back- 
wards, the  rectum  bulges  forward  as  a  tumor  {rectocele — Fig.  516), 
causing  constipation,  and  the  stretching  of  the  posterior  wall  leads 
to  retroversion  and  prolapse  of  the  uterus.  These  conditions  cause 
congestion,  and  hence  hemorrhoids  and  endometritis.  The  anterior 
vaginal  wall  also  may  prolapse  from  lack  of  support  of  the  posterior 


Fig.   510. — J^acerat'.on  oi  perineum 
and  large  rectocele. 


Fig.  517. — Diagram  of  cystocele  and 
rectocele.  Dotted  lines  represent  residual 
urine.  The  uterus  is  displaced  downwards 
and  backwards. 


wall,  or  from  descent  of  the  uterus,  causing  a  bulging  downwards 
and  outwards  of  the  bladder  {cystocele) ,  a  condition  which  may  exist 
likewise  without  laceration  of  the  perineum,  owing  to  the  submucous 
strippirg  of  the  anterior  vaginal  wall  from  the  underlying  parts 
during  labor.  A  cystocele  causes  dysuria,  and  sometimes  cystitis 
from  the  decomposition  of  residual  urine  (Fig.  517).  A  complete 
tear  causes  incontinence  of  feces  and  gas.  The  gaping  of  the  vaginal 
orifice,  the  backward  displacement  of  the  anus,  and  the  rectocele  or 
cystocele  are  readily  detected  by  inspection,  especially  when  the 
patient  strains.  By  palpation  wdth  a  finger  in  the  vagina  and  the 
thumb  externally  or  in  the  rectum,  the  gap  in  the  muscles  may  be 
felt. 

The  treatment  should  be  immediate  repair  after  labor  (perineor- 
rhaphy,   or   posterior   colporrhaphy),    the   divided   structures   being 


GENITAL   ORGANS 


925 


approximated  with  twenty-day  catgut.  Non-chromicized  catgut 
is  absorbed  very  rapidly  in  these  cases  and  should  not  be  employed. 
Of  the  secondary  operations,  i.e.,  those  in  which  the  laceration  is 
repaired  after  the  completion  of  cicatrization,  the  most  important 
are  described  below. 

Lateral  tears  are  best  repaired  by  the  Emmet  operation.  With 
the  patient  in  the  lithotomy  position,  guide  sutures  or  tenacula  are 
passed  through  the  apex  of  the  rectocele,  and  through  each  labium 
majus  at  the  lowest  carunculae  myrtiformes.  By  drawing  on  the 
lateral  suture  and  pulling  the  central  suture  downward  and  to  the 
opposite  side,  the  lateral  sulcus  appears  as  a  triangle  with  the  apex 
up  in  the  vagina.     This  triangle  is  denuded  of  mucous  membrane  by 


Fig.  518. — Emmet's  operation,  showing 
area  of  denudation.  A, A, A,  Guide  sutures; 
B,  upper  suture  passed  in  lateral  sulcus. 


Fig.     519. — Sulci    closed, 
stitch. 


A,    Crown 


cutting  off  long  strips  by  means  of  forceps  and  scissors,  or  by  dis- 
secting the  mucous  membrane  off  in  one  piece.  The  triangle  on  the 
opposite  side  is  treated  in  the  same  manner,  and  the  denudation 
completed  by  removing  the  mucous  membrane  between  the  bases 
of  the  triangles  and  below  the  central  suture  (Fig.  518).  Each 
lateral  triangle  is  closed  by  a  continuous  suture  of  chromicized 
catgut.  The  needle,  which  should  be  curved,  is  entered  near  the 
margin  of  the  wound  on  the  outer  side,  passed  deeply  to  catch  the 
fibers  of  the  levator  ani,  and  brought  out  at  the  bottom  of  the  sulcus, 
at  a  point  nearer  the  operator;  it  is  then  reinserted  at  the  bottom  of 
the  sulcus,  and  passed  upwards  and  backwards  in  the  rectocele,  to 
emerge  opposite  the  point  of  the  original  insertion.     The  opposite 


926 


MANUAL   OF    SURGERY 


triangle  is  treated  in  the  same  manner,  which  leaves  a  small  raw 
ai  ea  externally  to  be  closed  (Fig.  519).  The  upper  or  ' '  crown  stitch ' ' 
passes  through  the  skin  of  the  perineum  below  the  lateral  guide 
suture,  then  through  the  rectocele  below  the  central  guide  suture,  and 
finally  through  the  tissues  below  the  opposite  guide  stitch.  As 
many  sutures  as  may  be  necessary  are  inserted  below  this.  The 
external  genitals  are  irrigated  with  weak  bichlorid  of  mercury  solu- 
tion after  each  urination;  catheterization  should,  if  possible,  be 
avoided.  The  bowels  are  moved  on  the  second  day.  Internal 
douches  are  not  needed  unless  there  be  infection.  The  patient 
should  be  kept  in  bed  two  weeks,  and  heavy  work  and  sexual  inter- 
course forbidden  for  three  months. 


Fig.  521. — Flap-splitting  method  of 
perineorrhaphy.  Flap  elevated  and 
sutures  passed  through  the  levator  ani 
on  each  side. 


Hegar's  operation  (Fig.  520)  is  indicated  in  median  tears.  Lat- 
eral guide  sutures  are  placed  as  in  the  Emmet  operation  and  a 
central  guide  suture  is  inserted  in  the  middle  line  of  the  posterior 
vaginal  wall  as  high  as  may  be  necessary.  The  triangle  thus  out- 
lined is  denuded,  and  the  raw  surface  closed  by  interrupted  sutures 
passing  beneath  the  entire  denuded  area,  care  being  taken  to  catch 
the  transverse  perineal  muscle. 

The  flap-splitting  method  may  be  employed  in  either  lateral  or 
median  tears.  An  incision  is  made  around  the  lower  margin  of  the 
vulva,  joining  the  terminations  of  the  nymphae;  the  flap  separated 
from  the  rectum  and  drawn  upwards;  the  levator  ani  on  each  side 
clearly  defined,  and  the  muscular  edges  sutured  together  (Fig.  521); 


GENITAL    ORGANS  927 

the  skin  and  tissues  over  the  muscles  approximated;  and  the  flap 
fixed  in  position  with  a  few  additional  sutures. 

In  the  operation  for  complete  laceration  the  rectovaginal  septum 
is  split  laterally,  thus  separating  the  vagina  from  the  rectum  for  a 
short  distance  and  exposing  the  ends  of  the  sphincter  ani.  The 
wound  in  the  rectum  is  then  closed  by  two  layers  of  chromicized 
catgut  sutures,  one  for  the  mucous  membrane  and  a  second  for  the 
outer  coats.  The  sphincter  ani  is  approximated  by  two  or  three 
additional  catgut  sutures.  The  operation  is  then  completed  by  any 
one  of  the  methods  just  described,  the  lowest  external  suture  being 
passed  through  the  sphincter  ani.  In  order  to  avoid  fecal  contamina- 
tion of  the  wound  and  the  possibility  of  rectovaginal  fistula,  Ristine, 
Watkins,  and  others  make  a  vaginal  flap  with  the  base  downwards. 
The  depressions  corresponding  to  the  torn  ends  of  the  sphincter  ani 
are  joined  by  a  curved  incision,  through  the  vaginal  mucosa,  extend- 
ing a  half  inch  or  more  above  the  anal  margin.  This  "apron"  is 
reflected  downwards  over  the  anus,  and  the  sphincter  ani  united 
without  opening  the  rectum,  thus  converting  a  complete  into  and 
incomplete  tear,  which  is  closed  as  in  the  Hegar  or,  better,  as  in  the 
flap-spHtting  operation.  The  "apron"  may  be  fastened  up  over  the 
perineal  sutures,  so  as  to  protect  the  wound  from  the  rectal 
discharges. 

Anterior  colporrhaphy,  or  the  operation  for  cystocele,  consists  in 
removing  an  elliptical  piece  of  the  anterior  vaginal  wall,  extending 
from  just  behind  the  urinary  meatus  almost  to  the  cervix,  the  width 
depending  upon  the  degree  of  relaxation.  The  cervix  is  pulled  down 
with  a  tenaculum,  the  cellular  space  between  the  bladder  and  the 
vagina  opened  by  a  short  longitudinal  incision  near  the  cervix,  at 
which  point  there  is  little  danger  of  wounding  the  bladder,  blunt 
scissors  pushed  through  this  incision  almost  to  the  external  meatus, 
the  blades  separated  and  withdrawn,  and  the  space  thus  created 
exposed  by  continuing  the  longitudinal  incision  towards  the  meatus. 
Each  lateral  flap  is  now  raised  from  the  bladder  by  blunt  dissection, 
and  resected  by  a  curved  incision  as  far  out  as  may  be  necessary. 
The  wound  is  then  closed  with  two  or  three  layers  of  continuous 
catgut  sutures. 

Fistulae  are  usually  caused  by  sloughing  following  a  long  labor, 
but  are  occasionally  due  to  other  injuries,  and  sometimes  to  disease, 
such  as  syphilis,  tuberculosis,  or  cancer.  Those  due  to  disease  are 
not,  as  a  rule,  suitable  for  plastic  operations.  Urinary  fistulae  may 
be  urethrovaginal,  vesicovaginal  (the  most  common),  vesicouterine, 
ureter  ova  ginal,  or  ureteroiiterine.     The  most  common  fecal  fistula  is 


928  MANUAL   OF   SURGERY 

the  rectovaginal,  but  occasionally,  as  a  result  of  a  vaginal  operation  or 
injury,  the  vagina  communicates  with  the  small  bowel  {entero- 
vaginal  fistula).  These  fistulae,  with  the  exception  of  the  urethro- 
vaginal, in  which  leakage  occurs  only  during  micturition,  cause, 
according  to  their  character,  an  involuntary  escape  of  urine,  feces,  or 
gas  from  the  vagina,  and  all  give  rise  to  vulvovaginitis  as  the  result 
of  the  irritation  of  the  discharges.  Urinary  fistulse  may  be  compli- 
cated by  cystitis,  ureteritis,  and  pyelonephritis.  The  diagnosis  is 
made  by  passing  a  probe  or  finger  through  the  fistula,  or,  when  the 
orifice  is  very  small,  by  injecting  a  colored  fluid  into  the  bladder  or 
rectum  and  watching  for  its  escape  through  the  fistula.  In  ureteral 
fistulas  a  small  quantity  of  urine  constantly  dribbles  from  the  vagina 
despite  the  fact  that  micturition  is  normal,  and  the  color  and  quan- 
tity of  the  fluid  escaping  from  the  fistula  is  not  influenced  by  the 
injection  of  a  colored  solution  into  the  bladder. 

The  treatment  of  recent  small  fistulae  is  daily  irrigation  of  the 
vagina  with  boric  acid  solution  or  salt  solution,  never  with  strong 
antiseptics;  if  spontaneous  healing  does  not  occur  after  three  months, 
operation  should  be  advised.  Large  or  old  fistulae,  with  the  excep- 
tions noted  above,  always  require  operation.  Often,  however,  it  is 
first  necessary  to  remove  phosphatic  deposits,  to  combat  cystitis 
and  ulcerations,  and  to  improve  the  general  health,  A  vesicovaginal 
fistula  may  be  closed  by  paring  the  edges  of  the  orifice,  a  ad  then 
uniting  them  with  silkworm  gut  sutures,  which  penetrate  to,  but  not 
through,  the  bladder  mucous  membrane.  The  patient  is  usually 
placed  in  the  Sims  position  during  the  operation,  and  a  retention 
catheter  remains  in  the  bladder  after  operation.  The  sutures  are 
removed  in  ten  days.  If  the  edges  do  not  come  together  without 
tension,  a  longitudinal  incision,  which  is  subsequently  sutured 
transversely,  may  be  made  on  each  side  of  the  opening.  In  some 
cases  it  may  be  necessary  to  separate  the  bladder  from  the  vagina 
for  some  distance,  and  suture  each  cavity  separately.  Suture  of 
the  fistula  from  above,  after  the  bladder  has  been  opened  above  the 
pubes,  may  be  indicated  when  the  fistula  is  high  and  diflicult  to  reach 
through  the  vagina,  when  vaginal  operations  fail,  when  one  suspects 
that  the  ureters  are  close  to  the  orifice,  A  flirther  advantage  is  that 
the  bladder  is  put  at  rest  after  operation,  by  suprapubic  drainage. 
Of  thirty-three  cases  in  which  the  transvesical  operation  was  per- 
formed, success  followed  a  single  attempt  in  60  per  cent.  (Francey.) 
In  the  worst  cases  which  cannot  be  remedied  by  other  means,  the 
vagina  may  be  closed  below  the  opening  {colpocleisis) ,  thus  converting 
the  bladder  and  vagina  into  one  cavity.     Urethrovaginal  and  recto- 


GEXITAL    ORGANS  929 

vaginal  fistula  are  treated  on  the  same  principles  as  a  vesicovaginal 
fistula.  A  rectovaginal  fistula  close  to  the  vulva  may  be  incised  like  a 
fistula  in  ano,  and  then  treated  like  a  complete  laceration  of  the  peri- 
neum. A  vesicouterine  fistula  may  be  reached  by  dilating  or  splitting 
the  cerN^x.  Probably  the  best  operation  is  to  make  an  incision  in 
front  of  the  cervLx.  separate  the  bladder,  and  close  the  opening  in  it 
with  catgut  sutures.  Ureteral  fistulce  may  be  treated  by  establishing 
a  vesicovaginal  fistula  alongside  the  opening  in  the  ureter,  and  later 
closing  the  vesicovaginal  fistula,  which  now  includes  the  ureteral 
opening,  by  denuding  the  vaginal  mucous  membrane  about  the 
orifice  of  the  fistula,  and  subsequently  suturing  the  raw  surfaces. 
The  ureter  may  be  dissected  from  its  bed.  either  through  the  vagina  or 
abdomen,  and  anastomosed  with  the  bladder.  Anastomosis  with  the 
bowel  is  not  advisable.  When  all  other  plans  have  failed  or  cannot 
be  used,  and  the  opposite  kidney  is  healthy,  the  ureter  may  be  tied. 
Wlien  the  kidney  of  the  affected  side  is  extensively  damaged  from  an 
ascending  infection,  it  may  be  removed.  An  enterovaginal  fistula 
usually  demands  laparotomy,  the  intestine  being  separated  from  the 
vagina,  and  the  opening  in  each  closed  with  sutures. 

Vaginitis  is  usually  caused  by  gonorrhea,  but  may  be  due  to 
foreign  bodies,  or  other  conditions  mentioned  under  vulvitis.  In  old 
age  the  epithelium  is  prone  to  desquamate,  leaving  ulcers  {senile  or 
ulcerative  vaginitis),  which  may  result  in  stenosis  or  atresia.  As  in 
vulvitis,  gangrenous  and  croupous  inflammation  may  occur,  but 
cellulitis  {paracolpitis)  is  rare.  The  symptoms  of  the  acute  form  are 
pain  and  heat  in  the  vagina  and  pelvis,  vesical  and  rectal  irritability, 
a  mucopurulent  discharge,  and  reddening  of  the  mucous  membrane, 
which  is  frequently  studded  with  enlarged  papillae.  Chronic  vaginitis 
may  have  nothing  but  a  leukorrhea  to  indicate  its  existence.  Gonor- 
rheal vaginitis  can  be  diagnosticated  with  certainty  only  by  finding 
the  gonococci,  although  its  symptoms  are  often  very  acute,  and  it 
is  more  apt  to  be  associated  with  vulvitis,  urethritis,  and  infection 
of  the  vulvo-vaginal  glands.  Extension  to  the  uterus,  tubes,  ovaries, 
and  peritoneum  also  is  common. 

The  treatment  of  acute  vaginitis  is  rest  in  bed  and  the  general 

measures    advised    in    the    treatment    of    gonorrhea.     Douches    of 

bichlorid  of  mercury  (i  to  5,000)   or  permanganate  of  potassium 

(i  to  10,000)  may  be  given  several  times  a  day,  while  applications  of  a 

5  per  cent,  argyrol  solution  may  be  made  through  a  speculum  once 

daily,  and  the  vagina  lightly  packed  with  gauze  between  treatments. 

In  the  later  stages,  or  in  chronic  cases,  the  vaginal  mucous  membrane 

may  be  painted  with  silver  nitrate  fgr.  30  to  the  ounce)  several  times 
59 


930  MANUAL   OF    SURGERY 

a  week,  and  an  astringent  douche  of  zinc  sulphate  and  powdered 
alum  (each  half  an  ounce  to  a  quart  of  water)  may  be  ordered.  Ul- 
cerations are  treated  by  the  appHcation  of  silver  nitrate. 

Vaginismus  is  a  spasmodic  contraction  of  the  perivaginal  muscles, 
preventing  coitus  and  associated  with  excessive  hyperesthesia  of  the 
structures  about  the  vulva.  It  may  be  caused  by  a  urethral  caruncle 
or  other  local  disease,  and  is  most  common  in  the  neurasthenic. 

The  treatment  is  the  correction  of  any  local  disease,  and  gradual 
dilatation  by  means  of  bougies,  or  forcible  dilatation  under  a  general 
anesthetic.  Inveterate  cases  have  been  treated  by  excising  the  hy- 
men, or  by  incising  the  perineum  in  a  longitudinal  direction  and  clos- 
ing the  wound  transversely. 

Cysts  of  the  vagina  are  rare.  They  may  arise  from  retention  of 
secretion  in  one  of  the  vaginal  glands,  from  distention  of  lymph 
vessels  or  spaces,  from  a  hematoma,  from  the  echinococcus.  A 
cyst  of  Miiller's  duct  is  the  result  of  exudation  into  the  rudimentary 
portion  of  a  double  vagina;  it; may  reach  as  high  as  the  cervix 
uteri.  A  cyst  of  Gartners  duct  may  extend  up  through  the  wall 
of  the  uterus,  and  even  as  far  as  the  parovarium  (cf.  "Cysts  of  the 
Parovarium").  Gas  cysts  (emphysematous  vaginitis)  are  small  and 
multiple,  and  are  probably  the  result  of  saprophytic  decomposition 
of  the  secretion  retained  in  numerous  glands.  The  treatment  is 
excision,  except  in  the  last  instance,  in  which  the  cysts  may  be 
punctured,  and  the  vagina  douched  with  an  antiseptic  solution. 

THE  UTERUS 

Malformations  of  the  Uterus. — The  uterus  may  be  absent  or 
rudimentary,  in  the  latter  case  existing  as  a  thin  band  of  muscle  and 
connective  tissue. 

Congenital  atrophy  of  the  uterus  is  a  condition  in  which  the 
uterus  is  exceedingly  small,  the  size  of  the  cervLx  being  proportionate 
to  that  of  the  body.  An  infantile  uterus  is  small,  but  the  cervix 
is  two  or  three  times  longer  than  the  body,  a  condition  which  is 
normally  present  at  birth. 

The  remaining  malformations  of  the  uterus  are  due  to  non-union 
or  imperfect  fusion  of  the  ducts  of  Miiller.  Uterus  septus  is  one  in 
which  the  uterus  is  divided  longitudinally  by  an  antero-posterior 
septum.  Uterus  bicornis  is  one  in  which  the  uterus  is  divided  into 
two  horns  by  an  antero-posterior  groove  across  the  fundus.  When 
this  cleft  extends  to  the  vagina  there  are  two  uteri,  each  with  a  tube 
and  ovary  (uterus  didelphys).     When  one  of  the  canals  of  IM tiller 


GENITAL   ORGANS  93 1 

(Irx'clops  and  the  other  rciiiaiiis  rudimentary,  the  uterus  is  deflected 
to  one  side  (uterus  unicornis) .  In.  the  uterus  bipartitus  both  horns 
are  rudimentar)-,  hut  may  he  lioUow  and  eoiuu-cted  witli  the  \-agina 
and  with  each  other  by  the  cervix.  Some  of  these  malformations 
cause  steriUty,  others  miscarriages  or  great  difficulty  in  labor. 
When  the  uterus  is  so  poorly  developed  that  menstruation  amounts 
to  agony,  the  ovaries  may  be  removed.  When  the  uterus  is  divided 
by  a  septum,  such  may  be  crushed  with  forceps,  which  are  left  in 
place  until  they  come  away  of  themselves.  When  conception  takes 
place  in  a  rudimentary  horn,  the  condition  resembles  ectopic  preg- 
nancy, in  that  the  walls  may  break  and  a  fatal  hemorrhage  occur; 
in  such  a  case  the  rudimentary  horn  should  be  removed.  The  uterus 
didelphys  has  been  mistaken  for  pus  tubes  and  one  of  the  organs 
removed  before  the  mistake  was  discovered;  excision  is  the  proper 
procedure  if  there  is  a  unilateral  hematometra  or  pyometra. 

Atresia  of  the  cervix  (complete  closure)  may  be  congenital,  or  it 
may  be  acquired  as  the  result  of  tumors  of  the  cervix,  or  cicatrization 
following  the  application  of  caustics,  ulceration  due  to  infectious 
fevers,  injuries  of  childbirth,  or  a  badly  performed  trachelorrhaphy. 
There  is  retention  of  menstrual  blood  {hematometra) ,  mucus  (hydro- 
metra),  pus  {pyometra)^  or,  in  cases  infected  by  saprophytes  or  the 
gas  bacillus,  gas  (physometra) .  There  is  amenorrhea  with  the  sub- 
jective symptoms  of  menstruation  at  the  regular  periods,  except  in 
hydrometra,  which  usually  occurs  after  the  menopause.  In  pyo- 
metra and  physometra  septic  phenomena  are  in  evidence.  The 
uterus  is  enlarged  and  cystic  in  fluid  accumulations,  tympanitic 
or  crepitating  if  there  is  a  collection  of  gas.  The  treatment  is  punc- 
ture or  incision  of  the  cervix,  irrigation  of  the  uterine  cavity  with  salt 
solution,  and  the  subsequent  passage  of  bougies  to  maintain  the 
patency  of  the  canal.  The  condition  of  the  tubes  should  be  ascer- 
tained before  operation,  and  if  they  also  are  distended,  they  should 
be  removed  by  abdominal  section  before  emptying  the  uterus,  as 
such  is  apt  to  rupture  them  and  cause  peritonitis. 

Stenosis  of  the  cervix  (partial  closure)  may  be  due  to  the  same 
causes  as  atresia.  In  the  congenital  form  the  cervix  is  conical  and 
the  uterus  small  and  antefiexed.  The  symptoms  are  dysmenorrhea 
and  sterility,  the  latter  usually  being  caused  by  an  endocervicitis, 
which  induces  also  leukorrhea.  The  treatment  is  dilatation  of  the 
cervical  canal  by  a  glove-stretcher  dilator  (Fig.  522),  and  the  subse- 
quent passage  of  bougies  at  regular  intervals.  The  operation  is 
performed  by  seizing  the  anterior  lip  of  the  cervix  with  a  double 
tenaculum,  and  gently  passing  into  the  uterus  a  small  dilator,  the 


93- 


MANUAL   OF    SURGERY 


blades  of  which  are  separated  laterally,  and  then  in  other  directions, 
so  as  not  to  tear  the  cervix.  A  larger  and  more  powerful  dilator  may 
then  be  used  if  needed.  Dilatation  by  means  of  tents  (sponge, 
laminaria.  tupelo.  corn  stalk,  etc.)  which  expand  by  absorbing  mois- 
ture after  their  introduction  into  the  cervix,  is  slow,  painful,  and 
dangerous  because  they  are  difficult  to  render  and  keep  sterile. 
Dilatation  may  be  effected  also  by  repeated  packings  with  gauze, 
or  bv  the  Barnes  bag;  the  latter  consists  of  india  rubber  and  is  intro- 


PiG.  522. — Goodell's  uterine  dilator. 


duced  into  the  cervLx  collapsed,  after  which  it  is  slowly  distended 
with  air  or  water.  In  rare  instances  it  may  be  necessary  to  incise  the 
cerv'ix. 

Hypertrophy  of  the  cervix  may  involve  the  supravaginal  or 
infra  vaginal  portion;  the  former  is  associated  with  prolapse  of  the 
uterus  and  eversion  of  the  vaginal  mucous  membrane,  the  latter  is 
congenital  and  is  not  associated  with  displacement  of  the  fundus  of 


Fig.   523. — (Auvard.) 


Pig.  524- 


the  Uterus  or  obliteration  of  the  vaginal  fornices.  In  the  congenital 
variety  the  os  is  small  and  the  cervdx  long  and  conical.  Hyper- 
trophy of  the  cer\^ix  may  cause  leukorrhea,  sterility,  and  dysmenor- 
rhea, and  if  the  cervix  protrudes  from  the  \-ulva.  it  may  become 
ulcerated  and  interfere  with  locomotion.  The  treatment  is  amputa- 
tion of  the  cervix.  The  anterior  and  posterior  hps  of  the  cervix  are 
seized  with  double  tenacula,  the  cervix  split  transversely,  each  lip 
amputated  by  a  wedge-shaped  incision,  and  the  wound  closed  by 


GICNITAL    ORGANS  933 

sutures  as  shown  in  P'ig.  523.  Shroeder's  method,  which  is  indicated 
when  the  cervical  mucous  membrane  is  badly  diseased  is  shown  in 
Fig.  524.  The  cervix  is  split  as  in  the  ])revious  ()])eration,  and  each 
flap  amputated  in  a  manner  similar  to  removal  of  the  distal  phalanx 
of  the  finger  when  a  long  palmar  flap  is  used.  Chromicized  catgut 
is  the  best  suture  material. 

Laceration  of  the  cervix  is  usually  the  result  of  childbirth,  but 
occasionally  follows  attempts  at  abortion  or  dilatation  of  the  cervix. 
The  laceration  may  be  partial  or  complete,  the  latter  extending 
through  the  whole  cervix.  The  line  of  cleavage  is  apt  to  correspond 
with  the  right  oblique  diameter  of  the  pelvis,  because  the  most 
frequent  presentation  is  the  left  occipito-anterior.  The  laceration 
may  be  unilateral,  bilateral,  or  stellate,  i.e.,  having  more  than  two 
branches  radiating  from  the  cervical  canal.  Extensive  lacerations 
may  open  the  cellular  tissue  of  the  broad  ligaments  or  even  the 
I)eritoneum,  and  be  followed  by  cellulitis  or  peritonitis.  Symptoms 
may  be  absent,  particularly  in  unilateral  lacerations.  In  a  bilateral 
laceration  the  lips  are  separated,  exposing  the  cervical  mucous 
membrane  {ectropion  or  eversion),  which  becomes  raw  and  inflamed 
(erosion  of  the  cervix),  and  frequently  studded  with  small  retention 
cysts,  owing  to  obstruction  of  the  mouths  of  the  cervical  glands 
{cysts  or  ovules  of  Naboth) .  These  changes,  with  the  irritation  of  the 
cicatrices,  lead  to  subinvolution  and  chronic  inflammation  of  the 
uterus,  and  predispose  to  its  displacement,  sterility,  abortion,  and 
epithelioma.  The  most  prominent  symptoms  are  usually  a  feeling 
of  weight  and  discomfort  in  the  pelvis,  menorrhagia,  leukorrhea, 
suboccipital  headache,  and  neurasthenia.  The  diagnosis  is  readily 
made  by  palpation,  and  by  inspection  with  the  aid  of  a  speculum. 

Treatment  at  the  time  of  laceration  is  not  advisable  unless  there 
is  excessive  hemorrhage,  when  the  laceration  should  be  closed  with 
sutures.  After  the  puerperium  erosions  may  be  touched  every 
other  day  with  silver  nitrate  (grains  20  to  the  ounce),  the  cysts  of 
Naboth  punctured,  tampons  saturated  with  boroglycerid  inserted 
into  the  vagina  every  other  day,  and  copious  douches  of  hot  water 
given  daily.     If  this  treatment  fails  to  relieve,  operation  is  indicated. 

Emmet^s  trachelorrhaphy,  or  suture  of  the  laceration,  is  per- 
formed as  follows :  The  cervix  is  exposed  by  retracting  the  perineum 
with  a  speculum,  and  each  lip  caught  with  a  double  tenaculum. 
The  edges  of  the  laceration  are  denuded  with  scissors  or  knife, 
leaving  a  strip  of  mucous  membrane  in  the  middle  for  the  cervical 
canal,  all  the  scar  tissue  excised,  and  sutures  of  chromic  catgut 
inserted  and  tied   (Fig.   525).     It  is  usually  advisable  to  precede 


934 


MANUAL   OP   SURGERY 


this  operation  by  curetting  the  uterus.  In  stellate  tears  with  much 
scar  formation  and  hypertrophy  of  the  cervix,  amputation  is  gen- 
erally the  better  operation. 

Endometritis,  or  inflammation  of  the  mucous  membrane  lining 
the  uterus,  may  be  acute  or  chronic. 

Acute  endometritis  involves  both  the  cervical  and  corporeal 
endometrium  and  extends  to  the  underlying  tissues.  It  is  usually 
caused  by  infection  following  labor  or  abortion,  by  gonorrhea,  or 
by  the  use  of  infected  instruments,  but  it  may  be  due  also  to  acute 
infectious  fevers,  and  exposure  to  cold  during  menstruation.  The 
mucous  membrane  is  swollen,  softened,  and  intensely  hyperemic. 
There  may  be  extravasations  of  blood  into  the  uterine  walls  and 
the  formation  of  abscesses.  The  symptoms  in  mild  cases  are  a 
mucopurulent  discharge,  often  bloodstained,  pain  in  the  back  and 

pelvis,  irritability  of  the  bladder, 
and  a  little  fever.  The  uterus  is 
slightly  enlarged  and  tender,  the 
cervLx  softened,  and  the  os  fre- 
quently surrounded  by  an  area  of 
erosion.  In  the  severer  forms  the 
discharge  is  very  foul,  the  tender- 
ness more  marked,  and  the  general 
symptoms  those  of  sepsis.  The 
infection  often  spreads  to  the 
Fallopian  tubes  and  peritoneum; 
in  other  instances  it  involves  the 
body  of  the  uterus,  or  causes  a 
phlebitis  of  the  pelvic  or  other 
veins;  and  finally  it  may  spread 
through  the  lymphatics  and  cause  a  pelvic  cellulitis. 

The  treatment  is  rest  in  bed,  liquid  diet,  saline  laxatives,  hot 
vaginal  douches  of  bichlorid  (i  to  5,000)  twice  daily,  and  an  ice  cap 
tojthe  hypogastrium.  In  the  more  severe  forms  the  uterine  cavity 
itself  may  be  irrigated  with  a  solution  of  bichlorid  (i  to  10,000)  or 
normal  salt  solution.  When  occurring  after  labor  or  abortion,  the 
uterine  cavity  should  be  explored  with  the  finger  and  any  decompos- 
ing secundines  or  blood  clot  removed.  Curettage  is,  as  a  rule, 
contraindicated.  Septicemia  will  require  appropriate  general  treat- 
ment. In  the  worst  cases,  particularly  if  abscesses  form  in  the 
uterine  wall,  hysterectomy  may  be  indicated. 

Chronic  endometritis  may  involve  the  entire  endometrium,  but 
is  often  localized  to  the  cervical  or  corporeal  portion. 


Pig.   525. — Trachelorrhaphy. 


GENITAL    ORGANS  935 

Chronic  cervical  endometritis  or  catarrh  (endocerviciiis)  may  be 
due  to  any  of  the  conditions  producing  a  vaginitis  or  endometritis, 
the  inflammation  spreading  to  the  cervix  from  these  regions.  Lacer- 
ations and  gonorrhea  are  the  most  frequent  causes.  It  may  be  due 
also  to  stenosis  of  the  cervix.  The  entire  cervix,  including  the 
epithelium,  the  glands,  and  the  connective  tissue,  is  involved.  The 
cylindrical  epithelium  lining  the  cervix  spreads  out  over  the  vaginal 
portion,  giving  it  a  raw  appearance,  which  is  called  an  erosion,  and 
sometimes  erroneously  an  ulceration.  True  ulceration  of  the  cervix 
is  seen  in  chancre,  chancroid,  tuberculosis,  neoplasms,  prolapse  of 
the  uterus,  and  after  traumatism.  In  endocervicitis  the  mucous 
membrane  is  often  thrown  into  transverse  folds,  and  the  blood  vessels 
may  be  dilated  as  to  resemble  hemorrhoids.  The  enlarged  glands 
are  often  constricted  by  the  increased  amount  of  connective  tissue, 
thus  forming  retention  cysts  (ovules  of  Naboth).  The  symptoms 
are  pain  in  the  back,  irregular  menstruation,  and  leukorrhea.  The 
discharge  from  the  cervix  is  thick  and  viscid,  and  this  is  often 
sufficient  to  prevent  conception.  The  cervix  is  usually  enlarged 
and  tender.  The  changes  described  above  may  be  made  out  by 
palpation  and  by  the  use  of  the  speculum. 

The  treatment  is  attention  to  the  general  health,  and  the  use 
of  hot  vaginal  douches  containing  sulphate  of  zinc  (one  dram  to  the 
pint)  or  corrosive  sublimate  (i  to  5,000).  If  stenosed,  the  cervix 
should  be  dilated;  if  lacerated,  sutured.  Cysts  should  be  punctured, 
and  the  cervix  may  be  scarified  if  there  is  much  congestion.  In 
some  cases  it  may  be  necessary  to  apply  tincture  of  iodin,  ichthyol 
(25  per  cent,  in  lanolin),  or  silver  nitrate  (gr.  30  to  the  ounce)  to 
the  cervical  canal,  following  the  application  by  a  glycerin  tampon. 
Displacement  of  the  uterus  or  other  complication  should  of  course 
be  corrected.  In  inveterate  cases  the  uterus  should  be  curetted 
and  packed  with  gauze,  or  Schroeder's  operation  performed. 

Chronic  corporeal  endometritis  may  follow  the  acute  form,  but 
is  more  often  chronic  from  the  beginning;  in  the  latter  instance 
it  is  due  to  the  extension  of  an  endocervicitis  or  vaginitis,  or  to  any 
condition  which  induces  congestion,  e.g.,  excessive  coitus,  dis- 
placements of  the  uterus,  pelvic  tumors,  and  in  fact  almost  any 
pelvic  disease,  as  well  as  tight  lacing,  and  chronic  disease  of  the 
heart,  lungs,  liver,  or  blood.  In  many  of  these  cases  no  bacteria  can 
be  recovered  from  the  endometrium.  According  to  the  tissue  more 
involved  the  inflammation  is  designated  glandular  or  interstitial. 
When  the  changes  are  equally  distributed,  the  mucous  membrane 
is  thick,  soft,  and  smooth;  when  some  portions  are  more  involved 


936  MANUAL   OF   SURGERY 

than  others,  the  surface  presents  vascular  or  glandular  vegetations 
{villus  or  fungous  endometritis) .  As  in  the  cervix,  the  orifices  of  the 
glands  may  be  occluded  and  cysts  formed.  In  exfoliative  endo- 
metritis, or  membranous  dysmenorrhea,  at  each  menstruation  the 
epithelium  is  thrown  off  in  shreds,  or  in  one  whole  piece  as  a  cast 
of  the  uterus.  The  symptoms  are  pain  in  the  pelvis  and  back, 
mucopurulent  leukorrhea,  menorrhagia  or  metrorrhagia,  dysmenor- 
rhea, reflex  nervous  disturbances,  and  often  sterility  or  abortions. 
The  uterus  is  usually  enlarged  and  slightly  tender.  WTien  the 
disease  occurs  after  the  menopause  {senile  endometritis),  the  dis- 
charge may  be  retained,  giving  rise  to  an  offensive  odor  which 


Fig.   526.^ — Sims'  sharp  curette. 

suggests  malignant  disease,  a  suspicion  which  may  be  dispelled  by 
a  microscopic  examination  of  the  tissue  removed  by  the  curette. 
As  in  acute  endometritis,  the  inflammation  may  spread  to  the 
extrauterine  structures. 

The  treatment  in  the  absence  of  acute  inflammation  in  the 
periuterine  structures,  is  curettage.  With  the  patient  in  the 
Hthotomy  position,  the  anterior  lip  of  the  cervix  is  grasped  with 
tenaculum  forceps,  and  the  canal  dilated  with  the  glove-stretcher 
dilator.  The  curette  (Fig.  526)  is  then  introduced  and  the  walls 
of  the  cavity  systematically  gone  over  several  times,  a  grating 
sensation  being  imparted  to  the  hand  when  the  mucous  membrane 


Fig.  527. — Martin's  curette. 

has  been  removed.  For  curettage  of  the  fundus  and  cornua  the 
IMartin  curette  (Fig.  527)  should  be  employed.  The  uterine  cavity 
is  irrigated  with  bichlorid  of  mercury  solution  (i  to  10,000)  and  the 
vagina  filled  with  sterile  gauze.  The  uterus  should  not  be  packed 
unless  there  is  free  bleeding,  as  the  gauze  plug  interferes  with  drain- 
age. All  gauze  should  be  removed  at  the  end  of  twenty-four  hours, 
and  a  daily  vaginal  douche  of  bichlorid  of  mercury  (i  to  10,000) 
given  thereafter.  The  dangers  of  the  operation  are  perforation  of 
the  uterus,  inflammation  of  the  adnexa,  and  peritonitis.  The 
patient  should  remain  in  bed  one  week.  The  cause  of  the  endo- 
metritis, e.g.,  lacerations,  displacements,  etc.,  should,  if  possible. 


GKNITAL    ORGANS  937 

be  removed  at  the  time  of  the  curettage.  Strychnin  and  ergot  may 
be  given  after  operation,  in  order  to  encourage  contraction  of  the 
uterus. 

Acute  metritis,  or  inflammation  of  the  uterine  muscle,  is  due  to 
the  same  causes  as  acute  endometritis,  with  which  it  is  always 
associated,  and  from  which  it  cannot  be  differentiated  clinically. 
The  symptoms  and  treatment  are,  therefore,  those  of  acute 
endometritis. 

Chronic  metritis,  chronic  parenchymatous  inflammation  oj  the 
uterus,  difuse  interstitial  metritis,  or  subinvolution,  as  it  is  called 
when  following  labor,  may  be  due  to  (a)  causes  which  interfere  with 
normal  involution  of  the  puerperal  uterus,  e.g.,  retained  secundines, 
cervical  laceration,  acute  endomeritis,  pelvic  inflammation,  rising 
too  soon  after  confinement,  nonlactation,  and  repeated  miscarriages; 
and  to  (b)  causes  which  produce  repeated  or  protracted  congestion 
such  as  chronic  endometritis,  uterine  displacements,  pelvic  tumors, 
excessive  coitus  or  masturbation,  tight  lacing,  and  chronic  disease 
of  the  heart,  lungs,  or  liver.  At  first  the  uterus  is  large,  soft,  tender, 
and  h}Tperemic,  later  the  connective  tissue  gradually  increases  in 
amount  and  compresses  the  blood  vessels,  rendering  the  organ  hard 
and  anemic.  The  symptoms  are  those  of  the  compHcating  chronic 
endometritis,  with  a  feehng  of  weight  in  the  pelvis,  chronic  in- 
validism, and  neurasthenia.  The  increase  in  the  size,  weight,  and 
firmness  of  the  uterus  is  readily  detected  by  bimanual  examination. 
The  cervical  canal  is  dilated  and  the  uterine  cavity  uniformly  enlarged. 
The  complications  are  displacement  of  the  uterus,  chronic  endo- 
metritis, and  extension  of  the  inflammation  to  the  appendages  and 
the  peritoneum. 

The  treatment  is  removal  of  the  cause  (displacements,  lacer- 
ations, tumors,  etc.) ,  curettage  for  the  chronic  endometritis,  copious 
hot  vaginal  douches,  glycerin  tampons,  the  internal  administration 
of  ergot  and  strychnin,  and  the  general  treatment  for  neurasthenia. 
The  cervix  may  be  scarified,  or  painted  with  iodin,  or,  if  it  is  much 
enlarged,  it  may  be  amputated. 

Atrophy  of  the  uterus  is  normal  after  the  menopause.  It  may 
follow  destruction  or  removal  of  the  ovaries,  exhausting  general 
diseases,  and  certain  nervous  affections.  When  following  labor, 
it  is  called  superinvolution.  The  symptoms  are  amenorrhea,  sterility, 
and  reflex  nervous  disorders.  The  treatment  is  unsatisfactory. 
Attention  to  the  general  health  and  electricity  locally  may  be  useful. 

Displacements  of  the  uterus  are  pathological  when  they  are  more 
or   less  permanent  and  interfere  with  the  normal  mobility  of  the 


938 


MANUAL    OF    SURGERY 


organ.  The  uterus  may  be  displaced  upwards  (ascent)  or  downwards 
(prolapsus);  it  may  be  tilted  (version)  or  bent  (flexion)  forwards 
(anfeversion  or  anteflexion)  backwards  (retroversion  or  retroflexion), 
or  laterally  (later over sion  or  later o flexion);  it  may  be  turned  inside 
out  (inversion) ;  and  the  body  may  be  twisted  on  the  cervix  (torsion 
of  the  uterus).  Dislocation  of  the  uterus  is  a  displacement  of  the 
whole  organ,  wdth  little  or  no  change  in  its  axis;  it  may  be  forwards 
(anteposition) ,  backwards  (retro position) ,  or  lateral  (latero position) . 
Ascent,  latero  version,  lateroflexion,  torison,  and  dislocation  of  the 
uterus  are  due  to  exudates  or  neoplasms  which  push  the  uterus,  or 
to  adhesions  which  pull  the  uterus,  into  its  abnormal  position;  the 
treatment  is  that  of  the  causative  lesion. 

Anteversion  (Fig.  528)  may  be  caused  by  any  condition  which 
increases  the  weight  of  the  uterus  (e.g.,  metritis  and  tumors),  and 
bv  adhesions  which  draw  the  fundus  forward  or  the  cervix  backward. 


Fig.   528. — Anteversion  of  uterus. 
(Montgomery.) 


Fig.  529. — Acute  anteflexion. 
(Montgomery.) 


The  symptoms  are  those  of  the  causative  lesion,  with  those  of  pres- 
sure on  the  bladder,  i.e.,  frequent  micturition  and  hypogastric 
pain.  The  treatment  is  directed  to  the  condition  producing  the 
displacement. 

Anteflexion  (Fig.  529)  is  an  exaggeration  of  the  normal  forward 
bend  in  the  uterus,  with  rigidity  at  the  point  of  flexion.  It  may  be 
congenital,  or  the  result  of  metritis,  inflammation  of  the  uterosacral 
hgaments  which  draws  the  upper  part  of  the  cervix  upwards  and 
backwards,  irregular  involution  after  labor,  or  tumors  of  the  fundus. 
In  some  cases  the  uterus  falls  backwards  (retroversion  with  ante- 
flexion). The  symptoms  are  dysmenorrhea,  sterility,  frequent 
micturition,  leukorrhea,  and  the  symptoms  of  any  accompanying 
inflammation.  The  cervix  is  often  conical,  with  a  small  os,  and 
lies  in  the  axis  of  the  vagina,  while  the  fundus  may  be  felt  anteriorly. 
The  condition  is  dift'erentiated  from  tumors  and  exudates  in  front 


GENITAL   ORGANS 


939 


of  the  uterus,  by  dellnitcly  locating  the  fundus  by  bimanual  or 
rectal  examination.  The  sound  should  rarely  be  employed  to 
determine  the  direction  of  the  canal  and  the  position  of  the  fundus. 

The  treatment  is  dilatation  of  the  cervix,  curettage  of  the  uterus, 
and  the  maintenance  of  dilatation  by  the  passage  of  graduated 
sounds  weekly  for  a  month  or  more.  Stem-pessaries  and  tents 
are  dangerous.  Any  extrauterine  inflammation  should  of  course 
receive  appropriate  treatment.  Dudley  spUts  the  posterior  lip  of 
the  cervix  and  removes  a  wedge-shaped  piece  from  each  margin 
of  the  incision,  subsequently  uniting  the  diamond-shaped  wound 
with  transverse  sutures,  thus  enlarging  the  os  posteriorly.  Noiirse 
splits  the  cervix  laterally,  and  attempts  to  straighten  the  uterus 
by  pulling  on  the  posterior  lip,  which  is  then  sutured  in  its  new 
position.  Others  have  divided  the  uterosacral  ligaments,  or  re- 
moved a  wedge-shaped  portion  of  the  posterior  wall  of  the  uterus 
opposite  the  flexion,  the  canal  being  straight- 
ened by  suturing  the  incision. 

Retroflexion  and  retroversion  are  com- 
monly associated,  constituting  the  condition 
called  retroversio-fiexio  (Fig.  530).  As  a  rule 
the  uterus  first  retroverts,  and  is  later  bent 
backwards  by  the  action  of  the  intraabdomi- 
nal pressure  upon  the  anterior  face  of  the 
fundus.  The  causes  are  subinvolution  and 
relaxation  of  the  ligaments  following  labor, 
particularly  if  the  patient  gets  up  too  early; 
violent  jars  or  severe  straining;  salpingitis, 

the  tubes  f alHng  backwards  and  carrying  the  fundus  with  them ;  pelvic 
adhesions;  tumors  of  the  uterus  or  tissues  in  front  of  it;  lacerations  of 
the  perineum;  and  habitually  allowing  the  bladder  to  become  over- 
distended.  Some  cases  are  said  to  be  congenital,  the  posterior  wall 
of  the  vagina  failing  to  elongate,  thus  pulhng  the  uterus  backward. 
The  uterus'^is  usually  enlarged  and  congested,  and  there  is  practically 
always  a  compHcating  endometritis.  Symptoms,  in  the  absence 
of  complications,  are  often  absent.  In  a  typical  case  there  is. lum- 
bosacral pain,  occipital  headache,  a  feeling  of  weight  in  the  pelvis, 
leukorrhea.  menorrhagia,  dysmenorrhea,  frequent  micturition  from 
pressure  of  the  cervix  on  the  bladder,  constipation  and  hemorrhoids 
from  pressure  on  the  rectum,  sterility  or  abortions,  and  neurasthenia 
or  hysteria.  On  examination  the  uterus  is  found  low  in  the  pelvis, 
the  cervix  often  pointing  forward,  and  the  fundus  is  found  posteriorly. 
In  tumors  or  exudates  in  Douglas's  cul  de  sac,  and  in  feces  in  the 


Fig.  530. — Retroversio-flexio. 

(Montgomery). 


940  MANUAL   OF    SURGERY 

rectum,  the  fundus  is  found  anteriorly,  a  fact  which  may,  if  necessary, 
be  verified  with  the  sound.  The  direction  of  the  cervix  is  not  of 
much  value  in  differential  diagnosis.  Feces  have  a  doughy  feel 
and  can  be  identified  by  passing  a  finger  into  the  rectum. 

The  treatment  varies  according  to  whether  the  retroversion  is 
acute  or  chronic,  and  according  to  the  presence  or  absence  of  compli- 
cations. Acute  retroversion,  i.e..  occurring  after  labor,  miscarriage 
or  an  accident,  should  be  treated  by  replacing  the  uterus,  and  the 
assumption  of  the  knee  chest  posture  (Fig.  531)  for  five  minutes 
night  and  morning.  WTien  involution  is  complete  (six  weeks  after 
labor),  a  pessary  may  be  inserted  and  worn  for  several  months. 
About  one-third  of  the  cases  are  thus  cured.  If  the  displacement 
recurs  after  the  removal  of  the  pessary,  the  patient  should  be  allowed 
to  choose  between  an  operation  and  the  permanent  use  of  a  pessary. 
A  chronic  retroversion  without  symptoms  or  complications  requires  no 
treatment.     If  there  are  symptoms,  the  patient  may  choose  between 

operation  and  the  permanent 
use  of  a  pessary,  if  such  can  be 
worn  with  comfort.  The  pes- 
sary in  chronic  cases  is  to  be 
regarded  as  a  crutch,  as  it  is 
very  rarely  curative.  Retrover- 
sion with  complications  (lacera- 

FiG.   53i.-^^enupectoral  position.  ^^^^^  ^^  ^-^^  ^^^^.^^  ^^  perineum, 

endometritis,  salpingitis,  adhe- 
sions, etc.)  requires  operation  primarily  for  the  complications,  the 
uterus  being  brought  forward  and  held  in  place  by  some  operative 
procedure  at  the  same  sitting. 

Reposition  of  a  retroverted  uterus  may  be  efi'ected  by  placing  the 
patient  in  the  dorsal  position,  and  pressing  the  fundus  upwards  with 
two  fingers  in  the  vagina  until  it  can  be  caught  by  the  external  hand, 
when  the  vaginal  fingers  press  backwards  on  the  cervLx.  If  the 
fundus  is  caught  behind  the  promontory  of  the  sacrum,  the  cervix 
may  first  be  dra^Ti  downwards  with  tenaculum  forceps.  Another 
method  is  to  place  the  patient  in  the  Sims  or  knee  chest  posture,  and 
then  to  press  the  fundus  upwards  and  forwards  with  two  fingers  in 
the  vagina  until  it  passes  the  sacral  promontory,  when  the  vaginal 
fingers  draw  the  cer^-ix  backwards.  Reposition  by  introducing  a 
sound  into  the  cavity  of  the  uterus  and  using  it  as  a  lever  is  dangerous 
and  should  not  be  employed.  WTien  the  uterus  is  fixed  by  adhesions, 
abdominal  section  is  the  best  treatment.  If  the  patient  refuses  this 
and  the  surgeon  can  assure  himseh  that  there  are  no  pus  collections, 


GENITAL   ORGANS  94 1 

gradual  reposition  may  be  tried,  the  adhesions  being  stretched  by 
greatly  pushing  the  fundus  upward,  and  then  the  posterior  vaginal 
fornix  packed  with  a  tampon.  This  is  repeated  every  forty-eight 
hours,  and  when  the  fundus  has  ascended  well  into  the  abdomen, 
the  tampon  is  packed  into  the  anterior  fornix,  in  order  to  press  the 
cervix  backwards.  Schultze's  method  of  forcibly  breaking  up  the 
adhesions  under  an  anesthetic  is  too  dangerous  to  be  recommended. 
Pessaries  are  used  to  hold  the  uterus  in  a  forward  position  after 
it  has  been  replaced.  They  should  be  made  of  hard  rubber,  and 
various  sizes  will  be  needed  for  individual  cases.  Those  most 
commonly  employed  are  shown  in  Figs.  532,  533,  534.  The  advant- 
age of  the  Smith  pessary  is  the  bend  of  the  anterior  bar,  which  pre- 
vents pressure  on  the  urethra;  the  Hodge  pessary  does  not  possess 
this  bend,  but  is  more  useful  in  a  relaxed  vagina;  the  Thomas  pessary 
possesses  a  broad  posterior  bar,  which  more  equally  distributes 
pressure,  thus  avoiding  ulceration.  A  pessary  acts  by  stretching 
the  posterior  vaginal  wall  and 
pulling  the  cervix  backwards, 
and  not  by  supporting  the  fundus 
of  the  uterus.  It  is  contraindi- 
cated  in  the  presence  of  acute  in- 
flammation, and  should  be  em- 
ployed only  after  the  uterus  has 
been  replaced.  It  may  be  im-  p^^  ^3^  p^^  ^^3  p^^  ^^^ 
possible  to  retain  a  pessary  if  the        Hodge  Smith  Thomas 

,  ^,  .  pessary.  pessary.  pessary. 

cervix  IS  very  short  or  the  peri- 
neum extensively  torn;  in  the  latter  instance  the' difficulty  may  be 
remedied  by  perineorrhaphy,  but  it  is  better  to  perform  an  opera- 
tion for  the  cure  of  the  retrodisplacement  at  the  same  sitting.  The 
length  and  breadth  of  the  pessary  needed  may  be  ascertained  by 
passing  two  fingers  well  up  into  the  posterior  fornix  and  separating 
them.  The  shape  of  the  pessary  may  be  modified  after  oiling  it  and 
heating  it  over  a  lamp;  it  is  then  rendered  firm  by  plunging  it  into 
cold  water.  The  pessary  is  introduced  as  follows,  the  patient  being 
in  the  dorsal  or  the  Sims  position:  It  is  held  by  its  smaller  end  and 
the  broader  extremity  passed  into  the  vagina  parallel  with  the  labia, 
pressure  being  made  downward  against  the  perineum.  It  is  then 
turned  transversely,  the  broader  extremity  curving  upwards  and  the 
narrow  end  downwards.  The  index  finger  of  the  disengaged  hand 
is  passed  beneath  the  pessary  and  over  its  inner  end,  which  is  thus 
guided  upwards  and  backwards  behind  the  cervix.  The  lower  end 
of  the  pessary  should  reach  the  middle  of  the  urethra,  and  it  should 


942  MANUAL   OF    SURGERY 

be  possible  to  pass  the  finger-tip  between  the  pessary  and  vaginal 
wall  at  all  points.  If  the  pessary  is  too  large,  ulceration  may  follow. 
The  patient  should  take  a  daily  douiche,  and  the  pessary  should  be 
removed,  cleansed,  and  reinserted  every  month  or  two. 

Operations  for  retroversion  are  very  numerous  and  no  one  is  ideal. 
Those  which  are  most  frequently  employed  are  Alexander's  operation, 
hysteropexy,  and  intraabdominal  shortening  of  the  round  ligaments. 
Alexander's  operation  consists  in  opening  each  inguinal  canal  as  in  a 
hernia  operation,  and  drawing  out  the  round  ligaments  until  the 
fundus  reaches  the  anterior  abdominal  wall,  the  peritoneum  being 
stripped  from  the  ligament  as  it  is  pulled  outwards.  The  wounds 
are  closed  as  in  the  Bassini  operation,  the  sutures  including  the  round 
ligament,  the  excess  of  which  is  cut  off.  The  operation  is  indicated 
in  cases  in  which  the  uterus  is  freely  movable,  and  in  which  there 
are  no  intraabdominal  complications.  The  disadvantages  are  its 
limited  field,  the  difficulty  sometimes  encountered  in  finding  the 
ligaments,  the  occasional  breaking  of  a  ligament,  and  the  possibility 
of  hernia  from  the  pulling  out  of  a  pouch  of  peritoneum,  an  accident 
which  can  always  be  avoided. 

Hysteroplexy,  or  ventral  suspension  is  performed  through  a  small 
medium  abdominal  incision  or  through  the Pfannenstiel  incision.  The 
latter  runs  in  a  slight  curve,  with  the  convexity  downward,  within  the 
hair  line  of  the  pubes  and  across  the  recti  muscles.  The  skin,  subcu- 
taneous tissues  and  the  anterior  sheaths  of  the  recti  are  dissected  up  as 
one  layer,  the  recti  separated  in  the  direction  of  their  fibres,  the  trans- 
versalis  fascia  and  the  peritoneum  opened  by  a  vertical  cut.  This 
incision  leaves  an  inconspicuous  cicatrix  and  is  a  safe  guard  against 
hernia.  It  is  particularly  indicated  in  conservative  operations; 
contraindicated  in  suppurative  'lesions  because  of  the  extensive 
dissection  of  the  cellular  tissue.  In  hysteropexy  the  uterus  is 
brought  forward  and  the  fundus  sutured  to  the  lower  angle  of  the 
wound  by  two  silk  sutures,  each  passing  through  the  peritoneum  and 
subperitoneal  connective  tissue  a,nd  the  fundus,  the  first  on  a  line 
with  the  Fallopian  tubes  and  the  second  about  one-third  inch  post- 
eriorly, thus  anteverting  the  uterus.  In  time  the  uterus  recedes 
from  the  abdominal  wall  by  stretching  the  bond  of  union,  thus  form- 
ing an  artificial  ligament.  The  operation  allows  the  separation  of 
adhesions  and  the  treatment  of  other  intraabdominal  complications, 
but  has  the  disadvantages  of  occasionally  interfering  with  labor,  and 
of  forming  a  band,  about  which  intestinal  strangulation  may  occur. 
Ventrofixation  is  a  term  applied  to  the  same  operation  when  the 
sutures  fixing  the  uterus  pass  through  the  muscles  and  aponeurosis 


GENITAL   ORGANS  943 

of  the  abdominal  wall;  it  should  never  be  employed  unless  the  ovaries 
have  been  removed  or  the  menopause  has  arrived. 

Intraabdominal  shortening  of  the  round  ligaments  possesses 
the  advantages  of  hysteropexy  and  the  Alexander  operation  and  the 
disadvantages  of  neither.  Operations  which  shorten  these  ligaments 
by  folding  them  on  themselves,  by  fastening  them  to  the  anterior 
surface  of  the  uterus,  or  by  drawing  them  through  the  broad  ligament 
and  fastening  them  together  behind  the  uterus,  are  objectionable  in 
that  the  greatest  strain  is  brought  to  bear  upon  the  weakest  portion 
of  the  round  ligament  in  the  inguinal  canal.  The  Gilliam-Fergusoti 
operation  utilizes  the  strongest  part  of  the  ligament.  After  open- 
ing the  abdomen  in  the  median  line  a  pair  of  forceps  is  pushed  through 
the  outer  edge  of  the  rectus  muscle,  and  the  round  ligament  grasped 
about  two  inches  from  its  uterine  end;  the  forcep  is  withdrawn  and 
the  ligament  sutured  to  the  fascia  covering  the  rectus  muscle. 
Montgomery  has  modified  the  Simpson  operation.  A  silk  Hgature  is 
passed  beneath  each  round  ligament  about  one  and  one-half  inches 
from  the  uterus.  The  two  ends  of  the  ligature  are  threaded  into  a 
pedicle  needle,  which  is  introduced  between  the  layers  of  the  broad 
ligament,  and  carried  forward  extraperitoneally  until  it  reaches  the 
outer  border  of  the  rectus  muscle,  through  which  it  is  thrust,  the 
round  ligament  being  rendered  taut  to  facilitate  this  maneuver. 
The  ligature  is  withdrawn  from  the  needle,  and  serves  to  pull  the 
ligament  through  the  abdominal  wall,  where  it  is  fastened  with  cat- 
gut sutures.  As  there  is  some  danger  of  hernia  occurring  at  the 
point  where  the  round  ligament  passes  through  the  rectus,  we  have 
further  modified  this  operation  by  carrying  the  ligament  between  the 
rectus  and  its  superficial  sheath,  to  the  median  line,  where  it  is  sutured 
to  its  fellow. 

Prolapse  or  descent  of  the  uterus  is  divided  into  three  degrees, 
(i)  retroversion  with  sinking  of  the  organ  in  the  pelvis,  (2)  presenta- 
tion of  the  OS  at  the  vulva,  and  (3)  prolapse  of  the  uterus  between  the 
thighs  (Fig.  535).  The  first  and  second  are  called  incomplete, 
the  last  complete  prolapse,  or  procindentia.  The  causes  are  (i)  lack 
of  support  due  to  relaxation  of  the  uterine  ligaments  or  of  the  pelvic 
floor,  particularly  following  laceration  of  the  perineum ;  (2)  increased 
weight  of  the  uterus,  especially  subinvolution  after  labor;  and  (3) 
increased  intraabdominal  pressure,  such  as  is  produced  by  straining, 
lifting  heavy  weights,  improper  clothing,  and  abdominal  tumors. 
Occasionally  prolapse  is  suddenly  produced  by  a  severe  injury,  such 
as  a  crush,  or  a  fall  from  a  height.  The  symptoms  in  an  acute  case 
are  severe  pain,  and  possibly  internal  hemorrhage  and  peritonitis. 


944 


MANUAL    OF    SURGERY 


In  the  ordinary  chronic  f(jrm  there  are  first  rectocele  and  cystocele, 
then  retroversion  and  gradual  descent  of  the  uterus,  which  causes  a 
dragging  sensation  in  the  pelvis  and  back,  dysuria,  and  constipation ; 
in  complete  prolapse  there  may  be  difficulty  in  walking,  and  ulcera- 
tion of  the  protruding  mass  is  not  uncommon.  As  chronic  endometri- 
tis is  always  present  the  symptoms  of  this  affection  are  added  to 
those  just  mentioned.     In  pseudo prolapse,  or  hypertrophy  of  the 


Pig.  535. — Complete  prolapse  or  procidenture. 


cervix,  the  fundus  is  found  in  its  normal  situation  and  the  vaginal 
walls  are  not  displaced.  Inversion  of  the  uterus  presents  no  os,  but 
shows  the  orifices  of  the  Fallopian  tubes;  it  is  smaller  above  than 
below,  and  on  bimanual  examination  a  depression  is  found  in  the 
region  where  the  fundus  ought  to  be. 

The  treatment  is  reduction  of  the  prolapse,  and  maintenance  of  the 
uterus  in  its  normal  position  by  pessaries  or  by  operation.     Reduc- 


GENITAL   ORGANS  945 

lion  is  occasiDiially  dilTicult  because  of  edema;  strangulation  with 
gangrene  of  the  uterus  has  occurred  in  rare  cases.  If  edema  prevents 
reduction,  multiple  punctures  should  be  made,  cold  compresses 
applied,  and  the  foot  of  the  bed  elevated  for  some  hours.  Pessaries 
are  not  curative,  but  may  be  employed  if  the  patient  refuses  opera- 
tion, or  if  operation  is  contraindicated.  If  the  perineum  is  intact, 
a  retroversion  pessary  may  be  tried,  or  if  this  fails,  a  ring  pessary. 
When  pessaries  of  this  character  cannot  be  retained,  the  uterus  may 
be  held  up  by  a  cup  and  stem  pessary  (Fig.  536)  which  is  fastened  to 
an  abdominal  belt.  The  operative  treatment  consists  in  curettage, 
amputation  of  the  cervix  to  lessen  the  weight  of  the  uterus,  anterior 
colporrhaphy  and  perineorrhaphy  to  narrow  the  vagina  and  support 
the  uterus,  and  intraabdominal  shortening  of  the  round  ligaments 
before,  and  ventrofixation  after,  the  menopause.  If  the  uterus  is 
badly  diseased  or  contains  ''fibroids."  a  supravaginal  hysterectomy 
may  be  performed  and  the  stump  sutured  to  the  abdominal  wall.    Wat- 


FiG.   536. — Goddard  pessary. 

kins  and  Wertheim  have  recently  revived  vaginal  fixation  of  the  uterus 
in  the  treatment  of  prolapse  after  the  menopause.  The  anterior 
vaginal  wall  is  incised  longitudinally,  the  bladder  separated  from 
the  vagina  and  the  uterus  by  blunt  dissection,  and  the  vesicouterine 
fold  of  peritoneum  opened.  The  fundus  of  the  uterus  is  then  brought 
down  into  the  vagina,  the  vesical  fold  of  peritoneum  sutured  to  the 
posterior  surface  of  the  uterus  near  the  cervix,  and  the  fundus 
attached  to  the  vaginal  flaps  near  the  urethra.  The  incision  in  the 
vagina  is  now  closed  by  suturing  the  flaps  together.  Thus  the  uterus, 
turned  upside  down,  lies  between  the  bladder  and  the  anterior  wall 
of  the  vagina. 

Inversion  of  the  uterus  is  a  condition  in  which  the  uterus  is  partly 
or  completely  turned  inside  out.  There  are  three  degrees:  (i)  the 
intrauterine,  in  which  the  depressed  fundus  does  not  protrude  from 
the  cervix,  (2)  the  intravaginal,  in  which  the  fundus  protrudes 
through  the  cervix,  and  (3)  the  extravaginal,  in  which  the  inverted 

60 


946  MANUAL   OF    SURGERY 

Uterus  protrudes  from  the  vulva.  It  arises  during  the  puerperium 
as  the  result  of  traction  on  the  cord,  or  pressure  on  the  fundus  of  the 
uterus  (acute  inversion),  or  in  non-puerperal  cases  as  the  result  of  the 
dragging  of  a  pedunculated  intrauterine  tumor  (chronic  inversion). 
An  intussusception  is  thus  formed,  the  depressed  portion  being 
swallowed  by  the  undepressed  portion.  The  tubes  and  ovaries 
may  or  may  not  lie  within  the  inverted  uterus.  The  symptoms  of 
acute  inversion  are  pain,  shock,  hemorrhage,  and  the  detection  of  a 
mass  in  the  vagina.  Chronic  cases  develop  gradually  and  are  asso- 
ciated with  metrorrhagia,  leukorrhea.  dragging  pains  in  the  pelvis 
and  back,  and,  from  pressure  on  the  bladder  and  rectum,  dysuria 
and  constipation.  In  intrauterine  or  partial  inversion  a  cupping  of 
the  fundus  may  be  felt  on  bimanual  examination,  and  the  depressed 
portion  may  be  detected  by  a  sound  in  the  uterus.  When  the  inver- 
sion is  complete,  the  mass  is  detected  in  the  vagina  or  outside  the 
vulva,  the  uterus  cannot  be  found  in  its  normal  situation,  and  the 
cup-shaped  depression  may  be  felt  on  bimanual  examination.  A 
sound,  or,  better,  the  finger,  may  be  passed  around  the  tumor,  but 
will  enter  the  cervix  for  a  short  distance  only,  or  not  at  all.  The 
mass  is  sensitive,  bleeds  easily,  is  larger  below  than  above,  and  may 
show  the  orifices  of  the  Fallopian  tubes.  The  condition  must  be 
differentiated  from  prolapse  (q.v.)  and  from  polypi.  In  the  latter 
the  uterus  is  in  its  normal  situation,  and  a  sound  cannot  be  passed  all 
around  the  base  of  the  tumor,  but  enters  the  uterine  cavity  at  one 
side  and  reveals  it  to  be  of  normal  or  increased  depth. 

The  treatment  is  reduction,  usually  with  the  aid  of  a  general 
anesthetic.  Emmet's  method  consists  in  passing  the  fingers  around 
the  tumor  and  into  the  cervix,  in  order  to  press  upon  the  fundus  with 
the  palm  of  the  hand  while  the  fingers  dilate  the  cervical  ring,  counter- 
pressure  being  made  with  the  other  hand  through  the  abdominal 
wall.  Xoeggerath  pushes  on  one  horn  of  the  uterus  with  the  finger, 
thus  reinverting  the  fundus  and  finally  the  body.  Prolonged  pres- 
sure on  the  fundus  may  be  employed  by  gauze  packing  or  an  elastic 
vaginal  bag.  Special  apparatus  also  has  been  invented  to  make 
pressure  on  the  fundus  and  pull  down  the  cervLx.  If  these  measures 
fail  the  posterior  lip  of  the  cervix  may  be  cut  through  in  the  median 
line,  the  uterus  reduced,  and  the  cervical  wound  sutured.  Other 
operations  for  this  condition  are  stretching  of  the  cer^'ical  ring 
through  an  abdominal  incision,  and  reduction  by  traction  on  the 
fundus;  opening  the  peritoneal  cavity  through  the  mass,  followed 
by  dilatation  of  the  cerv-ical  ring,  suture  of  the  wound,  and  reposition 
of  the  uterus;  and  vaginal  hysterectomy. 


GENITAL   ORGANS  947 

Fibromyomata  or  "fibroids"  of  the  uterus  are  slow-growing, 
encapsulated  tumors  composed  of  fibrous  and  muscular  tissue, 
the  fibrous  tissue  being  in  excess.  When  the  muscular  tissue  pre- 
dominates, the  term  myofibroma  is  applicable.  Pure  myomata  are 
rare,  grow  rapidly,  and  are  not  encapsulated.  Fibroids  arise  during 
the  period  of  sexual  activity,  and  never  before  puberty  or  after  the 
menopause,  in  fact,  subsequent  to  the  climacteric  they  usually  remain 
stationary  or  atrophy.  They  are  most  frequent  in  the  colored 
race  and  in  the  married,  sexual  excitement  and  pregnancy  both  in- 
creasing the  rate  of  growth.  Twenty  per  cent,  of  all  women  who 
have  reached  the  age  of  thirty-five  are  said  to  have  fibroids.  These 
tumors  are  almost  always  multiple  and  vary  greatly  in  size.  The 
body  of  the  uterus,  particularly  the  posterior  wall,  is  the  favorite 
situation.  According  to  their  relations  with  the  uterine  wall,  they 
may  be  interstitial,  submucous,  or  sub- 
peritoneal (Fig.  537);  the  second  and  subpehitoiheal  ,.. 
third  varieties  may  be  sessile  or  pedun- 
culated. A  pedunculated  submucous 
growth  is  called  a  fibrous  polyp.  The 
uterus  is  enlarged,  and  the  mucous  mem- 
brane hypertrophied  and  sometimes  ulce- 
rated. According  to  the  situation  of  the 
growth,  the  uterus  may  ascend,  descend,  ^^^bmucoos. 
or  be  pushed  toward  one  of  the  walls  of 
the  pelvis,  while  a  submucous  growth 
may  cause  inversion.     In  40  per  cent,  of  Pig-  537.— Diagram  showing  the 

^,  /-r-,1      1  \     1  .1  ,1        varieties  of  uterine  fibromyomata. 

the  cases  (rleck)  there  is  brown  atrophy 

of  the  heart,  a  fact  accounting  fox  some  of  the  sudden  deaths  after 
operation.  In  54  per  cent.  (Tait)  there  are  inflammatory  changes  in 
the  tubes  or  ovaries.  The  changes  which  may  occur  in  the  tumor 
itself  are  edema,  suppuration,  gangrene,  calcification,  atrophy  (es- 
pecially after  castration  or  the  menopause),  and  fatty,  amyloid, 
myxomatous,  cystic,  or  sarcomatous  degeneration  (1-2  per  cent.). 
The  growth  may  be  associated  also  with  chondroma  or  osteoma,  or 
carcinoma  of  the  endometrium. 

The  symptoms  are  (i)  hemorihage  (menorrhagia,  metrorrhagia, 
and  delayed  menopause),  especially  in  the  submucous  variety;  (2) 
pain  due  to  dysmenorrhea,  particularly  in  submucous  growths,  or 
caused  by  peritonitis  or  pressure  on  the  pelvic  nerves;  (3)  sterility 
or  miscarriages;  and  (4)  those  due  to  pressure  on  the  urethra  or 
bladder  (dysuria,  frequent  micturition,  retention,  cystitis),  on 
the   ureter   (hydronephrosis,   pyonephrosis),   on   the  rectum    (con- 


948  MANUAL   OF   SURGERY 

stipation,  tenesmus,  obstruction,  hemorrhoids),  on  the  pelvic  nerves 
(pain  or  numbness) ,  on  the  pelvic  veins  (varicosities  and  edema  of  the 
leg,  phlebitis),  and  during  labor  (dystocia).  Symptoms  may,  how- 
ever, be  absent  in  even  large  growths.  The  uterus  is  irregularly 
enlarged  and  often  filled  with  hard  masses.  A  submucous  fibroid 
may  be  recognized  with  the  sound,  or  with  the  finger  after  dilatation 
of  the  cervix.  Pregnancy,  particularly  when  associated  with  bleed- 
ing, may  be  mistaken  for  a  fibroid.  In  these  cases  the  cervix  is 
softened  and  the  positive  signs  of  pregnancy  will  sooner  or  later  be 
detected.  It  should  be  remembered  that  the  uterine  souffle  may 
often  be  heard  in  large  fibroids  and  that  intermittent  contractions 
of  the  uterus  can  sometimes  be  felt.  Examination  with  the  Rontgen 
rays  may  show  the  fetus  after  the  fourth  month  of  pregnancy.  Per- 
haps Abderhalden's  sero-diagnosis  for  pregnancy  may  prove  of  value. 
In  doubtful  cases  the  best  diagnostic  agent  is  time.  It  is  not  unusual 
to  mistake  other  tumors  or  chronic  inflammatory  troubles  of  the 
pelvis  for  a  fibroid.  A  subperitoneal  fibroid  with  a  long  pedicle  may 
easily  simulate  a  growth  of  a  neighboring  organ. 

Treatment  is  not  needed  in  the  absence  of  symptoms.  If  s}Tnp- 
toms  are  present  the  treatment  may  be  palliative  or  radical.  Pallia- 
tive treatment  maybe  indicated  if  the  general  condition  of  the  patient 
is  bad  because  of  some  independent  affection,  or  if  the  symptoms 
are  shght,  complications  absent,  and  the  menopause  is  near.  Drugs 
like  ergot,  hamamelis,  hydrastis,  thyroid  extract,  pituitarin,  and  ad- 
renalin may  be  given  internally  for  hemorrhage,  and  such  occasion- 
ally lessen  the  size  of  the  growth.  Hygienic  treatment  includes  rest 
in  bed  for  a  portion  of  each  day,  and  the  avoidance  of  constipation, 
coitus,  tight  corsets,  prolonged  walking,  and,  in  short,  anything 
which  induces  pelvic  congestion.  Electrical  treatment  requires 
special  apparatus,  is  not  free  from  risk,  and  should  never  be  used  in 
complicated  cases;  it  is  said  to  reduce  the  size  of  the  tumor,  but  is 
of  most  value  as  a  hemostatic.  The  positive  pole  is  attached  to  a 
uterine  sound,  which  is  passed  into  the  uterus,  while  the  negative 
pole  is  placed  on  the  abdomen,  the  current  is  then  gradually  turned 
on  to  the  point  of  tolerance  and  so  maintained  for  five  minutes;  this 
may  be  repeated  once  or  twice  a  week.  Radiotherafy  (radium,  X- 
rays)  has  proved  of  service  as  a  hemostatic  agent,  and,  indeed,  accord- 
ing to  some  enthusiasts,  may  cause  the  growth  to  disappear.  A 
preliminary  curettage  is  always  done  to  exclude  malignancy,  and  to 
remove  any  polj-pi  that  may  be  present.  Radiotherapy,  owing  to 
its  destructive  action  on  the  ovaiies.  produces  an  artificial  menopause, 
and  is  attended  with  the  risk  of  burning.     Fistulas  have  followed  the 


GENITAL   ORGANS  949 

introduction  of  radium  into  the  uterus.  Althoujijh  final  conclusions 
cannot  be  drawn  at  the  present  time,  our  own  practice  is  to  advise 
against  radiotherapy  in  all  operable  cases.  In  the  young  the  ovaries 
can  be  left  when  the  uterus  is  removed;  at  or  after  the  menopause  the 
danger  of  malignancy  is  removed  with  the  uterus.  Curettage  followed 
by  packing  with  iodoform  gauze  is  a  valuable  measure  for  controll- 
ing hemorrhage.  Intrauterine  applications  of  iodin,  carbolic  acid^ 
and  other  hemostatics  also  have  been  used  for  the  metrorrhagia. 
Salpingo-obphorectomy  checks  the  bleeding  and  diminishes  the  size 
of  the  growth,  and  may  be  employed  in  cases  in  which  hysterectomy 
is  contraindicated,  because  of  its  difficulty  or  the  general  condition 
of  the  patient. 

Radical  treatment  consists  in  removal  of  the  growth  alone,  or  the 
entire  uterus,  either  through  the  vagina  or  through  the  abdomen. 

Removal  of  fibrous  polypi  when  small  may  be  effected  with  the 
curette;  growths  of  larger  size  may  be  twisted  off,  or  the  pedicle 
may  be  cut  with  scissors  or  with  the  wire  ecraseur.  Hemorrhage 
following  any  of  these  operations  is  controlled  by  gauze  packing. 

Vaginal  enucleation  of  submucous  fibroids  may  be  performed 
after  dilatation  or  incision  of  the  cervix,  the  capsule  being  incised^ 
and  the  tumor  shelled  out  with  the  finger  or  a  blunt  instrument. 
If  the  tumor  is  too  large  to  be  delivered,  it  may  be  reduced  in  size 
by  cutting  sections  out  of  it  {morcellement) . 

Vaginal  hysterectomy  is  rarely  indicated  for  libromyomata,  as  a 
tumor  large  enough  to  demand  radical  treatment  is  better  dealt 
with  through  the  abdominal  wall.  The  patient  is  placed  in  the 
lithotomy  position,  and  the  cervix  exposed  by  perineal  and  lateral 
retractors,  and  seized  with  strong  tenaculum  forceps.  The  peritoneal 
cavity  is  opened  by  a  curved  incision  behind  the  cervix  and  by  a 
curved  incision  in  front  of  the  cervix,  care  being  taken  not  to  injure 
the  bladder.  The  uterine  artery  on  each  side  is  then  ligated,  making 
sure  that  the  ureter  is  not  included  in  the  ligature.  The  broad  liga- 
ment between  the  ligature  and  the  uterus  is  cut,  the  uterus  drawn 
farther  down,  and  the  broad  ligament  ligated  in  sections  and  cut 
until  the  uterus  is  freed.  The  final  ligature  is  placed  to  the  outer 
or  inner  side  of  the  ovary,  according  to  whether  it  is  desirable  or  not 
to  remove  that  organ.  After  separating  the  cervix  from  the  vagina 
some  operators  turn  the  uterus  upside  down,  thus  bringing  the  fundus 
into  the  vagina,  and  ligate  and  cut  the  broad  ligament  from  above 
downward.  Others,  instead  of  ligatures,  use  clamps  which  are  re- 
moved at  the  end  of  two  or  three  days;  this  method  facihtates  the 
operation,  but  increases  the  danger  of  secondary  hemorrhage.     When 


950 


MANUAL   OF   SURGERY 


the  uterus  is  too  large  to  be  delivered  through  the  vagina,  it  may  be 
divided  into  halves  in  the  median  line  and  each  half  removed  sepa- 
rately, or,  if  it  is  still  too  large,  wedge-shaped  portions  may  be  ex- 
cised (morcellement)  from  its  center.  After  removal  of  the  uterus,  the 
peritoneum  and  vagina  maybe  sutured  or  the  wound  filled  with  gauze. 
Abdominal  myomectomy  consists  in  exposing  the  tumor  through 
an  abdominal  incision,  incising  its  capsule,  enucleating  the  growth, 
and  closing  the  uterine  wound  with  catgut  sutures.  The  operation  is 
sometimes  advised  in  the  young  in  whom  the  growths  are  few  and 
easily  accessible,  but  should  be  seldom  performed  because  of  the 
danger  of  leaving  unnoticed  fibroids,  and  because,  if  the  patient 
subsequently  becomes  pregnant,  the  scar  predisposes  to  uterine 
rupture.     In  pedunculated  subperitoneal  tumors,  the  pedicle  may 

be  ligated  if  small,  or  it  may  be 
excised  by  a  wedge-shaped  in- 
cision and  the  wound  in  the 
uterus  closed  with  sutures. 

Abdominal  hysterectomy 
may    be    partial    or    complete. 
Partial  or  supravaginal  hysterec- 
tomy is  the  operation  of  choice  in 
Fig.  538.— Diagram  of  siipravaginai  hys-  the  majority  of  cascs,  particularly 

terectomy,  showing  ligatures,   from   above    .  . 

downward,  on  the  ovarian  artery,  the  round    m  large  tumOrS,  m  the  presence  Of 

If  ^"i''"^u  ^""t  ^^^  ""T'^^  artery     The  degenerative  changes,  and  when 

bladder   has   been    pushed  downward,   and         '^  . 

the   uterus   amputated  by  a  wedge-shaped    the  tubeS  Or  OVaricS  are  diseased. 

incision.      The    dotted    lines    indicate    the    rr  ^.t.  •  U       IfVi  A  •(■V. 

situation  of  the  ureters,  which  pass  under  ^^  ^^ne  ovaries  are  ncaitny  and  tne 

the  uterine  arteries  about  three-fourths  of    patient  yOUng,  at  Icast  OnC  should 

an  inch  from  the  cervix. 

be  preserved,  in  order  to  avoid  the 
nervous  s>Tnptoms  induced  by  an  artificial  menopause.  A  median 
incision  is  made  below  the  umbihcus,  adhesions  separated,  the  uterus 
delivered  through  the  wound,  the  foot  of  the  table  raised  (Trende- 
lenburg posture),  the  intestines  pushed  upward  and  held  in  place 
with  gauze  pads,  and  each  broad  Hgament  severed  after  tying,  with 
catgut,  the  ovarian  artery,  the  round  ligament,  and  the  uterine 
artery,  clamps  or  hgatures  being  placed  on  the  uterine  edge  of  the 
broad  ligament  to  prevent  reflux  hemorrhage.  The  ligatures  are 
passed  through  the  broad  ligament  by  an  aneurysm  or  pedicle  needle 
and  may  be  of  silk  or  catgut.  The  ovarian  artery  may  be  tied 
to  the  outer  or  the  inner  side  of  the  ovary,  according  to  whether 
this  organ  is  to  be  removed  or  retained.  In  securing  the  uterine 
artery,  the  needle  must  be  passed  close  to  the  cervix,  in  order  to 
avoid  the  ureter.     The  two  incisions  in  the  broad  ligaments  are 


GENITAL   ORGANS  951 

now  joined  by  cutting  the  peritoneum  across  the  uterus  just  above 
the  bladder,  which  is  jnished  downward  with  the  handle  of  the 
knife.  A  similar  incision  is  made  posteriorly,  and  the  uterus  ampu- 
tated at  the  level  of  the  internal  os  by  a  wedge-shaped  incision  (Fig. 
538).  The  cervix  is  now  closed  with  cagut  sutures  which,  to  pre- 
vent prolapse,  should  include  the  ends  of  the  round  ligaments,  and 
the  peritoneum  approximated  over  the  stumps  of  the  arteries  and  the 
cervix  with  a  continuous  catgut  suture.  The  abdomen  is  closed 
without  drainage.  Complete  hysterectomy,  or  panhysterectomy,  is  to 
be  preferred  if  there  is  associated  malignant  disease  or  infection  of 
the  tumor,  or  fibroid  growths  in  the  cervix.  The  broad  hgaments 
are  ligated  and  divided  and  the  bladder  stripped  from  the  cervix,  as 
in  the  previous  operation.  An  incision  is  then  made  into  the  vagina 
through  Douglas's  cul  de  sac,  and,  aided  by  a  finger  passed  through 
this  opening  into  the  vagina,  the  incision  is  continued  all  around  the 
cervix  and  the  uterus  removed.  The  opening  in  the  vagina  is  then 
closed  with  sutures,  or  it  may  give  exit  to  a  gauze  drain  if  such  be 
needed.  When  there  are  intraligamentary  fibroids,  it  is  often  better 
to  sever  first  the  broad  ligament  on  the  unaffected  side,  then  to  cut 
through  or  around  the  cervix,  and  ligate  and  divide  the  opposite 
broad  ligament  from  below  upward  while  the  uterus  is  rolled  strongly 
toward  the  affected  side;  by  this  procedure  an  intraligamentary 
growth  is  turned  out  of  its  bed  and  the  danger  of  injury  to  the  ureter 
minimized. 

Polypi  of  the  uterus  are  pedunculated  tumors  springing  from  the 
mucous  membrane  of  the  body,  or  more  frequently  the  neck  of  the 
uterus.  Fibrous  polypi  have  been  considered  above.  Mucous 
polypi  are  soft  red  growths  composed  of  mucous  membrane.  Pedun- 
culated Nahothian  follicles  are  retention  cysts  of  the  cervical  glands 
which  have  acquired  pedicles.  Placental  polypi  are  undetached  por- 
tions of  the  placenta  which  retain  a  vascular  connection  with  the 
uterus.  A  papillomatous  polypus  may  spring  from  the  cervix,  and 
is  very  apt  to  become  malignant.  The  symptoms  are  bleeding, 
leukorrhea,  cramp-like  pains  due  to  the  expulsive  efforts  of  the  uterus, 
dysmenorrhea,  and  sterility.  When  the  polypus  protrudes  from  the 
OS,  it  is  easily  detected  with  the  finger  and  the  speculum.  Before 
this  time  it  may  be  overlooked,  but  may  be  recognized  either  with 
the  sound,  or  with  the  finger  after  dilatation  of  the  cervix.  The 
treatment  is  removal  by  seizing  the  tumor  with  a  pair  of  forceps, 
and  twisting  it  until  the  pedicle  gives  way,  or  the  pedicle  may  be 
cut  with  scissors,  the  galvano-cautery,  or  the  wire  ecraseur.  Small 
soft  polypi  may  be  removed  with  the  curette.  In  all  cases  the  growth 
should  be  studied  microscopically  to  exclude  malignant  disease. 


952  MANUAL  OF   SURGERY 

Sarcoma  of  the  uterus  i-  uncommon,  is  most  frequent  in  the 
body  of  the  uterus,  and  is  often  a  degenerative  process  in  a  fibro- 
myoma.  It  is  usually  of  the  spindle-celled  variety,  and  has  the  same 
tendencies  here  as  elsewhere.  The  symptoms  are  pain,  uterine 
hemorrhages,  watery  leukorrhea,  emaciation,  a  rapidly  growing 
tumor,  and  in  some  cases  ascites.  A  fibroid  which  grows  rapidly, 
continues  to  increase  in  size  after  the  menopause,  or  which  recurs 
after  removal,  strongly  suggests  sarcomatous  degeneration.  The 
treatment  is  complete  hysterectomy. 

Carcinoma  of  the  uterus  is,  following  carcinoma  of  the  stomach, 
the  most  frequent  form  of  malignant  disease  in  the  human  body.  It 
is  most  common  after  the  fortieth  year,  but  may  arise  in  early  life. 
The  influence  of  heredity  is  doubtful,  but  any  local  irritation,  such 
as  laceration  of  the  cervix,  polj-pus,  and  chronic  endometritis,  favors 
its  development.  In  over  80  per  cent,  of  the  cases  the  disease  origi- 
nates in  the  cervix.  It  may  be  squamous-ceUed  (epitheHo?na)  when 
springing  from  the  vaginal  portion  of  the  cervix,  or  cyhndrical-celled 
(adenocarcinoma)  when  attacking  the  cervical  canal  or  corporeal 
endometrium.  Epithelioma  of  the  cervix  begins  as  a  nodule  in  the 
vaginal  portion  of  the  mucosa,  from  which,  after  a  time,  finger-like 
projections  spring,  forming  a  cauliflower-like  mass;  or  as  the  result  of 
necrosis,  the  growth  appears  as  an  excavated  ulcer  with  hardened 
everted  edges.  Extension  is  most  rapid  in  the  direction  of  the  vagina, 
and  the  growth  involves  the  bladder  at  an  early  period.  Adenocarci- 
noma of  the  cervical  endometrium  soon  causes  enlargement  of  the  cerv- 
ical canal,  either  by  ulceration,  or  by  pressure  from  papillary  growths. 
The  disease  is  prone  to  extend  outward  into  the  parametrium  along 
the  bases  of  the  broad  Ugaments,  and  upward  into  the  body  of  the 
uterus,  long  before  it  invades  the  vaginal  portion  of  the  cervix;  the 
bladder,  and  less  frequently  the  rectum,  may  be  involved  in  the 
later  stages.  Cancer  of  the  fundus  projects  into  the  uterine  cavity 
as  a  fungous  mass,  which  ulcerates,  and  extends  through  the  uterine 
wall  to  the  environing  structures.  Cancer  of  the  uterus  in  most 
instances  involves  the  regional  lymph  glands,  only  after  it  has  ex- 
tended to  the  parametrium;  this  is  said  to  be  due  to  the  small  size 
of  the  lymph  vessels  of  the  uterus  and  the  large  size  of  the  epithehal 
cells.  Metastases  to  distant  portions  of  the  body  are  therefore  com- 
paratively infrequent.  Unchecked,  the  disease  is  usually  fatal  in 
from  SLX  months  to  two  years. 

The  symptoms,  in  the  usual  order  of  their  appearance,  are  hemor- 
rhage, offensive  discharge,  pain,  and  cachexia.  Pain  is  often  absent 
until  the  peritoneum  or  parametrium  is  involved,  while  cachexia  is 


GENITAL    OIU'.ANS  953 

often  i)()stpoiu'(l  uiUil  near  the  end;  consequently  to  wait  for  these 
signs  before  making  a  diagnosis  is  usually  to  wait  until  the  case 
is  inoperable.  Pressure  symptoms  similar  to  those  induced  by 
fibromyomata  (q.v.)  and  urinary  or  fecal  fistulae  from  ulceration 
involving  the  bladder  or  rectum  may  arise  in  the  final  stages.  Epi- 
thelioma of  the  vaginal  portion  of  the  cervix  can  be  recognized  with 
the  linger  or  speculum,  as  a  friable,  f ungating,  easily  bleeding  mass. 
In  carcinoma  of  the  cervical  canal  the  cervix  is  enlarged,  firmer  than 
normal,  and  sometimes  inliltrated  with  nodules,  and  the  growth  may 
be  felt  by  inserting  the  finger  into  the  cervical  canal.  Cancer  of  the 
fundus  causes  enlargement  of  the  uterus  and  may  be  felt  with  the 
sound.  In  doubtful  cases  a  portion  should  be  removed  for  micro- 
scopic examination,  by  excision  when  the  disease  is  in  the  cervix,  and 
by  the  curette  when  in  the  body  of  the  uterus.  Menorrhagia  at,  or 
metrorrhagia  subsequent  to  the  menopause,  is  so  strongly  suggestive 
of  cancer  as  to  demand  a  most  careful  investigation,  including 
microscopic  examination  of  suspected  tissue. 

The  treatment  is  palliative  or  radical.  Palliative  treatment  is 
indicated  in  inoperable  cases,  which,  unfortunately,  constitute  the 
vast  majority  of  those  coming  under  observation.  When  the  uterus 
is  fixed  in  the  pelvis,  indicating  invasion  of  the  parametrium,  or 
when  the  bladder  or  rectum  is  involved,  radical  operation  is  gen- 
erally contraindicated,  although  attempts  are  sometimes  made  to 
remove  a  portion  of  all  these  structures  with  the  uterus.  Hemor- 
rhage and  discharge  are  greatly  lessened,  and  life  prolonged,  by  re- 
moving as  much  of  the  growth  as  possible  with  a  curette,  and  cauteriz- 
ing the  raw  surfaces  with  the  Paquelin  cautery;  the  cavity  is  filled 
with  iodoform  gauze,  which  is  removed  at  the  end  of  twenty-four 
hours,  and  douches  of  permanganate  of  potassium,  creohn,  or  other 
antiseptic  deodorant  given  daily.  Care  should  be  taken  not  to 
perforate  the  uterus  during  this  operation.  Instead  of,  or  in  addition 
to  the  PaqueUn  cautery,  some  surgeons  insert  into  the  cavity  a 
tampon  containing  a  50  per  cent,  solution  of  chlorid  of  zinc,  which 
is  allowed  to  remain  several  days.  The  vagina  should  first  be  coated 
with  an  ointment  consisting  of  one  part  of  sodium  bicarbonate  to 
three  parts  of  vaselin.  Radiotherapy  may  lessen  the  discharge, 
the  fetor,  and  the  pain.  Nothing  short  of  opium  is  of  value  for  the 
excruciating  pain  in  the  later  stages. 

Radical  treatment  consists  in  removal  of  the  uterus  through  the 
vagina,  through  the  abdomen,  or  by  the  combined  method.  Vaginal 
hysterectomy  may  be  employed  when  the  vagina  is  large,  the  uterus 
small,  and  the  patient  very  stout.     The  operation  is  similar  to  that 


954  MANUAL   OF   SURGERY 

already  described  for  fibromyoma,  except  that  any  protruding 
carcinomatous  tissue  should  first  be  removed  with  the  curette  and  the 
cervix  closed  with  sutures,  and  hemisection  of  the  uterus  or  morcella- 
tion  should  never  be  employed.  Complete  abdominal  hysterectomy 
is  the  operation  of  choice,  as  it  allows  the  wide  removal  of  the  para- 
metrium and  of  any  enlarged  retroperitoneal  lymph  glands.  The 
operation  is  identical  with  that  described  for  fibroids,  except  that  the 
uterus  should  first  be  curetted,  packed  with  gauze,  and  the  cervix 
closed  with  sutures  in  order  to  prevent  infection  of  the  peritoneum 
when  the  vagina  is  opened,  and  the  uterine  arteries  should  be  ligated, 
not  close  to  the  cervix,  but  to  the  outer  side  of  the  ureters.  Com- 
bined vaginal  and  abdominal  hysterectomy  is  preferred  by  some  oper- 
ators. The  cervix  may  be  isolated  from  the  vagina  and  the  operation 
completed  through  the  abdomen;  or  the  broad  ligaments  may  be  tied 
and  divided  from  above,  the  abdomen  closed,  and  the  operation 
completed  through  the  vagina.  The  mortality  of  hysterectomy  for 
carcinoma  is  from  lo  to  20  per  cent.  The  chances  of  permanent 
cure  are  about  5  per  cent,  in  carcinoma  of  the  cervix,  and  about 
75  per  cent,  in  carcinoma  of  the  fundus. 

Endothelioma  of  the  uterus  is  rare  and  cannot  be  differentiated 
clinically  from  carcinoma.     The  treatment  is  complete  hysterectomy. 

Chorio -epithelioma,  deciduoma  malignum,  or  synctioma  malignum, 
is  a  malignant  growth  springing  from  the  chorionic  epithehum 
following  pregnancy.  The  growth  resembles  placental  tissue  in- 
filtrated with  blood.  The  symptoms  usually  arise  a  few  weeks  or 
months  after  a  normal  labor  or  an  abortion,  particularly  if  there  has 
been  a  hydatidiform  mole.  There  are  metrorrhagia  and  a  foul 
smelling,  watery  discharge,  and  later  pain.  The  os  is  dilated,  and 
the  uterus  laige  and  its  cavity  filled  with  a  friable,  purplish  mass, 
which  recurs  after  removal,  extends  to  the  surrounding  parts,  and 
quickly  gives  rise  to  distant  metastases.  The  diagnosis  is  made  with 
the  microscope.     The  treatment  is  immediate  complete  hysterectomy. 

DISORDERS  OF  MENSTRUATION 

Amenorrhea,  or  absence  of  menstruation,  is  normal  before 
puberty,  after  the  menopause,  and  during  pregnancy  and  lactation. 
The  pathological  causes  are  atresia  of  the  genital  canal  {concealed 
menstruation),  non-development  or  atrophy  of  the  generative  organs, 
destruction  of  the  ovaries  and  tubes  by  disease  or  their  removal  by 
operation,  exposure  to  the  X-rays  or  radium,  obesity,  emotional 
disturbances,  hysteria,  neurasthenia,  debihtating  diseases,  change  of 


GENITAL   ORGANS  955 

climate,  catching  cold  during  menstruation,  opium  and  other  drug 
habits,  hypothyroidism,  hypopituitarism,  and  most  frequently  of  all 
chlorosis.  I'lu'  treatment  is  that  of  the  cause.  Suppression  of  the 
menses  due  to  cold  is  treated  by  hot  drinks  and  hot  applications. 
Emmenagogues  are  rarely  indicated,  and  should  never  be  employed 
unless  pregnancy  can  be  positively  excluded. 

Vicarious  menstruation  is  the  periodic  discharge  of  blood  from 
some  other  part  of  the  body  than  the  uterine  mucosa.  It  may  occur 
from  any  mucous  membrane,  the  skin,  or  from  an  ulcer,  and  is 
usually  associated  with  amenorrhea  or  scanty  menstruation.  At- 
tempts may  be  made  to  induce  normal  menstruation  by  hot  douches, 
electricity  locally,  and  the  internal  use  of  emmenagogues,  such  as 
iron,  oxalic  acid,  aloes,  apiolin,  or  the  salicylates.  Irritating  appli- 
cations to  the  endometrium  are  dangerous. 

Menorrhagia  is  prolonged  or  increased  menstrual  bleeding. 
Metrorrhagia  is  bleeding  from  the  uterus  between  the  menstrual 
periods.  Among  the  local  causes  are  inflammatory  diseases,  dis- 
placements, injuries,  and  neoplasms  of  the  uterus  or  appendages, 
foreign  bodies  in  the  uterus,  pelvic  tumors  not  connected  with  the 
uterus,  placenta  previa,  detachment  of  the  placenta,  hydatidiform 
degeneration  of  the  chorion,  ectopic  pregnancy,  abortion,  sclerosis  of 
the  uterine  vessels,  and  most  common  of  all  fungous  endometritis. 
Among  the  general  causes  are  anemia,  hemophilia,  acute  infectious 
diseases,  emotional  disturbances,  gout,  scurvy,  sj^Dhilis,  malaria,  lead 
poisoning,  and  diseases  of  the  heart,  lungs,  and  liver  (cf.  '^Spon- 
taneous Hemorrhage,"  chap.  xv).  H}-perthyroidism  should  probably 
be  included  among  these  causes;  also,  from  a  theoretic  standpoint. 
h>Tperpituitarism,  although  positive  evidence  of  the  influence  of 
the  latter  on  the  menses  is  lacking. 

The  treatment  is  that  of  the  cause.  If  the  cause  cannot  be  found 
and  the  loss  of  blood  is  excessive  radiotherapy  is  the  best  hemostatic. 
In  an  emergency  the  bleeding  may  be  checked  by  packing  the  uterus 
tightly  with  gauze,  the  transfusion  of  human  blood  and  giving  horse 
serum  hypodermatically.  Various  other  measures  can  be  used  for 
the  same  purpose  (see  "Styptics,"  chap.  xv).  Uncontrollable  bleed- 
ing at  the  menopause  may  demand  hysterectomy. 

Dysmenorrhea  is  excessive  pain  just  before,  during,  or  immedi- 
ately after  the  menses.  Like  amenorrhea,  menorrhagia,  and  metror- 
rhagia, dysmenorrhea  is  a  symptom,  not  a  disease.  The  following 
varieties  are  described: 

Neuralgic  dysmenorrhea  is  most  frequent  in  the  anemic  and 
nervous,  and  may  or  may  not  be  associated  with  disease  of  the  pelvic 


956  MANUAL    OF    SURGERY 

organs.  The  pain  is  neuralgic  in  character,  and  may  be  referred  to 
the  uterus,  to  the  ovaries,  or  elsewhere.  It  is  apt  to  be  most  severe 
before,  and  is  occasionally  relieved  by  the  flow.  There  may  be 
neuralgia  in  other  parts  of  the  body.  The  treatment  is  attention  to 
the  general  health,  anemia,  gout,  rheumatism,  or  indigestion  and  the 
giving  of  appropriate  remedies.  In  some  instances,  according  to 
the  rhinologists,  the  dysmenorrhea  depends  upon  an  affection  of  the 
nose.  Any  local  disease  should  be  removed,  and  the  pain  itself 
relieved  by  hot  applications  and  the  administration  of  antineuralgic 
remedies  like  acetphenetidin,  cannabis  indica,  and  belladonna; 
elixir  of  valerianate  of  ammonium  (f  5ii)  or  fluid  extract  of  viburnum 
prunifolium  (f  5i)>  every  three  or  four  hours,  is  frequently  employed. 
In  cases  which  resist  all  other  forms  of  treatment,  removal  of  the 
ovaries  may  be  indicated. 

Congestive  dysmenorrhea  is  due  to  exposure  to  cold,  uterine 
displacement,  pelvic  tumors,  and  inflammations  of  the  uterus,  the 
appendages,  or  the  environing  structures.  These  conditions,  except- 
ting  the  first,  cause  intermenstrual  symptoms  and  may  be  recognized 
by  pelvic  examination.  The  symptoms  are  worst  at  the  beginning  of 
menstruation,  and  are  often  relieved  by  a  free  flow.  The  treatment 
during  the  attack  is  hot  applications,  hot  sitz  baths,  diuretics,  and 
diaphoretics.     Between  attacks  the  cause  should  be  removed. 

Mechanical  or  obstructive  dysmenorrhea  is  due  to  some  obstruc- 
tion to  the  egress  of  menstrual  fluid,  such  as  stenosis  of  the  cervix, 
flexions  of  the  uterus,  tumors  (particularly  polyps),  and  spasmodic 
contraction  of  the  internal  os.  There  are  severe,  cramp-like  pains 
{uterine  colic),  followed  by  a  gush  of  blood  or  the  expulsion  of  clots, 
which  usuafly  gives  relief.  Between  the  periods  the  passage  of  a 
sound  may  reveal  hyperesthesia  of  the  endometrium,  particularly 
about  the  internal  os.  The  treatment  is  dilatation  of  the  cervical 
canal  if  there  be  stenosis,  and  curettage  of  the  uterus  if  there  be 
endometritis.  Polypi  should,  of  course,  be  removed.  The  treat- 
ment of  flexions  has  already  been  considered.  Obstructive  dysmen- 
orrhea is  often  cured  by  labor,  which  permanently  dilates  the  cervical 
canal. 

Ovarian  dysmenorrhea  is  associated  with  disease  of  the  ovaries, 
the  symptoms  referable  to  these  organs  being  intensified  during  the 
menstrual  period.     The  treatment  is  that  of  the  causative  lesion. 

Membranous  dysmenorrhea  is  characterized  by  the  expulsion  of  a 
membrane,  the  decidua  menstrualis,  either  in  shreds  or  as  a  cast  of  the 
uterus.  It  is  differentiated  from  an  early  abortion  by  its  regular 
occurrence,  and  by  the  absence  of  chorionic  villi  in  the  membrane. 


GENITAL    ORGANS  957 

It  is  a  form  of  endometritis,  and  is  usually  associated  with  sterility. 
The  treatment  is  dilatation  and  curettage,  which  may  require  repeti- 
tion. 

Sterility  in  the  female  is  normal  before  puberty,  after  the  meno- 
jiause,  and  during  lactation,  although  conception  may  occur  during 
<any  of  these  periods.  At  other  times  it  may  be  due  to  preventive 
measures,  vaginismus,  exposure  to  the  X-rays  or  radium,  displace- 
ments or  atrophy  of  the  uterus,  laceration  of  the  perineum  sufficiently 
severe  to  interfere  with  retention  of  semen,  or  to  congenital  defects, 
stenosis,  atresia,  fistulae,  neoplasms,  or  inflammatory  diseases  of  any 
portion  of  the  genital  tract.  Among  the  general  conditions  which 
may  be  responsible  are  anemia,  debilitating  diseases,  obesity,  gout, 
syphilis,  locomotor  ataxia,  myelitis,  hypothyroidism,  hypopituita- 
rism, prolonged  use  of  certain  drugs  (alcohol,  arsenic,  bromides, 
chloral,  cocain,  camphor,  opium),  and  lack  of  affinity  between  the 
male  and  female.  It  should  be  recalled  that  in  about  one-fifth  of  the 
cases  the  fault  lies  with  the  male,  hence  in  order  to  be  complete, 
an  investigation  for  the  cause  of  sterility  should  include  an  examina- 
tion of  the  male  sexual  organs,  the  microscopic  examination  of  the 
semen  for  spermatozoa,  and  an  inquiry  into  the  potency  of  the  male. 
(See  "Impotency"  and  "Sterility  in  the  Male".)  The  treatment  is 
that  of  the  cause. 

THE  FALLOPIAN  TUBES 

Congenital  Anomalies. — The  tubes  may  be  absent  or  rudiment- 
ary, they  may  have  accessory  fimbriated  extremities,  and  the  tubal 
ducts  may  be  doubled  on  one  or  both  sides. 

Displacements  are  usually  downward  and  backward  as  the 
result  of  inflammatory  trouble.  The  tubes  accompany  displace- 
ments of  the  uterus  or  ovaries,  and  may  be  pushed  in  any  direction 
by  tumors. 

Salpingitis,  or  inflammation  of  the  Fallopian  tube,  is  usually  the 
result  of  extension  upward  of  an  endometritis;  its  causes,  therefore, 
include  those  of  endometritis,  particularly  gonorrhea,  the  use  of 
septic  instruments,  and  sepsis  following  labor  or  abortion;  occa- 
sionally the  inflammation  extends  from  the  peritoneum  or  neighbor- 
ing organs  other  than  the  uterus,  and  infection  is  sometimes  conveyed 
to  the  tube  by  the  blood  or  lymph  vessels.  The  organism  most 
frequently  found  is  the  gonococcus,  and  next,  in  the  order  of  their 
frequency,  the  streptococcus,  tubercle  bacillus,  colon  bacillus,  staphy- 
lococcus, and  pneumoccoccus.  In  most  of  the  tubes  removed  at 
operation,  cultures  are  negative,  the  organisms  having  perished.    The 


958  MANUAL   OF   SURGERY 

inflammation  first  involves  the  mucous  membrane,  then  spreads 
through  the  outer  walls  to  the  peritoneum  and  closes  both  ends  of  the 
tube.  The  secretions  accumulate  and  distend  the  tube,  particularly 
the  outer  two-thirds.  The  walls  may  be  either  thinned  or  thickened. 
The  tube  is  distorted,  adherent  to  adjacent  structures,  and  commonly 
displaced  downward  and  backward,  although  it  may  remain  in  its 
normal  situation  or  be  displaced  even  forward.  Hydrosalpinx,  or 
distention  of  the  tube  with  serum  or  mucus,  is  the  result  of  a  catarrhal 
inflammation;  such  a  sac  may  empty  itself  intermittently  into 
the  uterus  {hydrops  tuha  profliiens).  Hematosalpinx  is  distention  of 
the  tube  with  blood,  as  the  result  of  inflammation,  tubal  pregnancy, 
torsion  of  the  tube,  or  atresia  of  any  portion  of  the  genital  tract. 
Pyosalpmx  is  distention  of  the  tube  with  pus,  which  may  rupture  into 
the  bowel,  bladder,  vagina,  or  into  the  peritoneal  Cavity,  in  the  last 
instance  causing  a  pelvic  abscess  or  a  generalized  peritonitis.  Leak- 
age of  the  pus  from  the  abdominal  ostium  also  may  occur,  and  rarely 
the  infection  spreads  downward  between  the  layers  of  the  broad 
ligament,  giving  rise  to  pelvic  cellulitis  or  abscess  of  the  broad 
ligament. 

The  symptoms  are  pain  in  the  lower  abdomen,  most  marked  just 
above  Poupart's  ligament,  and  increased  by  walking,  jolting,  or 
straining;  leukorrhea;  dysmenorrhea;  menorrhagia;  sometimes  met- 
rorrhagia; usually  sterility;  and  disturbances  of  the  general  health. 
There  are  often  backache,  rectal  pain  intensified  at  stool,  and  some- 
limes  pain  in  distant  parts,  such  as  the  head,  the  breast,  the  epi- 
gastrium, or  the  thighs.  In  pyosalpinx  there  may  be  repeated 
attacks  of  pelvic  peritonitis  with  septic  symptoms.  On  bimanual 
examination,  pressure  on  the  uterus,  or  in  the  lateral  or  posterior 
fornix,  causes  pain;  the  uterus  is  usually  retroverted  and  adherent, 
and  the  distended  tubes  are  felt  behind  or  to  the  sides  of  the  uterus. 

The  treatment  may  be  medical  or  surgical.  Medical  treatment 
is  indicated  during  the  acute  stage,  during  acute  exacerbations  of  a 
chronic  inflammation,  and  in  chronic  cases  in  the  absence  of  suppura- 
tion. In  the  presence  of  acute  symptoms  with  fever,  the  patient 
should  be  confined  to  bed  and  be  given  a  liquid  diet.  An  ice  bag 
should  be  applied  to  the  hypogastrium,  copious,  hot  vaginal  douches 
given  twice  a  day,  and  the  bowels  thoroughly  moved  with  salts. 
Depletion  may  be  secured  also  by  scarification  of  the  cervix  and  gly- 
cerin tampons.  In  severe  cases  anodynes  and  stimulants  will  be 
required.  When  the  acute  symptoms  have  subsided,  absorption  of 
the  exudate  may  be  encouraged  by  the  application  of  iodin  to  the 
vaginal  fornices,  and  by  the  pressure  of  tampons  containing  glycerin 


GENITAL   ORGANS  959 

or  ichthyol,  which  should  be  removed  in  forty-eight  hours,  a  copious 
hot  douche  taken,  and  the  tampons  reinserted.  Curettage  of  the 
uterus  should  not  be  performed;  it  may  stir  the  chronic  inflammation 
to  renewed  activity. 

The  surgical  or  radical  treatment  of  salpingitis  is  indicated  in 
the  presence  of  pus,  and  in  cases  in  which  medical  treatment  fails  to 
give  relief;  in  other  words,  in  the  large  majority  of  cases.  The  tubes 
may  be  exposed  for  operative  attack  through  the  vagina  or  through 
the  abdomen.  In  vaginal  section  the  intestines  and  ureters  are  more 
apt  to  be  damaged,  bleeding  is  more  difficult  to  control,  secondary 
hemorrhage  is  more  frequent,  the  general  peritoneal  cavity  cannot 
be  protected,  and  disease  of  environing  organs,  particularly  the 
appendix,  cannot  be  treated  satisfactorily;  it  is,  therefore,  seldom 
indicated.  Abdominal  section  is  always  more  or  less  exploratory  in 
these  cases,  and  the  surgeon  should  secure  permission  to  do  that 
which  in  his  judgment  seems  best.  The  abdomen  is  opened  by  a 
median  incision  below  the  umbilicus,  the  table  raised  to  the  Trendel- 
enburg posture,  and  the  operative  field  isolated  with  gauze.  After 
identifying  the  fundus  of  the  uterus,  two  fingers  are  insinuated 
downward  along  its  posterior  surface  and  adhesions  separated  in  the 
lines  of  least  resistance,  the  fingers  passing  outward  and  usually 
unrolling  the  tube  from  below  upward.  Adhesions  may  require  the 
use  of  scissors  and  the  application  of  ligatures.  Should  pus  appear 
at  any  time,  it  is  caught  with  sponges  and  the  table  immediately 
lowered,  while  any  unavoidable  injury  to  the  bowel  should  be  closed 
at  once  with  sutures.  As  a  rule  both  tubes  and  ovaries  will  be  so 
extensively  diseased  as  to  require  removal  {salpingo-odphorectomy). 
This  may  be  done  by  passing  a  pedicle  needle  armed  with  catgut 
through  the  broad  ligament  and  below  the  round  ligament  (Fig. 
539);  the  loop  of  the  ligature  is  cut,  one-half  tied  around  the  tube 
close  to  the  uterus,  and  the  second  beneath  the  ovary.  The  ends  of 
one  of  these  ligatures  may  be  left  long  and  again  carried  around  the 
pedicle  and  tied,  always  using  a  surgeon's  knot  first  and  then  a  single 
knot.  The  tube  and  ovary  are  then  amputated  above  the  ligatures, 
leaving  sufficient  tissue  to  prevent  slipping.  This  method  is  easy 
and  quick,  but  may  be  followed  by  secondary  hemorrhage,  as  the 
ligatures  are  apt  to  loosen  from  shrinkage  of  the  stump  or  to  cut 
through  the  friable  tissues;  moreover,  the  large  area  left  uncovered 
by  peritoneum  predisposes  to  adhesions  and  intestinal  obstruction. 
A  better  way  is  to  pass  a  ligature  through  the  broad  ligament  to  the 
outer  side  of  the  ovary,  thus  including  the  infundibulo-pelvic  liga- 
ment and  the  ovarian  artery.     A  second  ligature  is  then  placed  in  the 


960 


MANUAL   OF    SURGERY 


angle  between  the  round  ligament  and  the  uterus,  securing  the  upper 
end  of  the  uterine  artery  (Fig.  539).  The  tube  and  ovary  are  re- 
moved by  cutting  close  to  them  with  scissors,  the  uterine  end  of  the 
tube  being  amputated  by  a  wedge-shaped  incision.  The  wound  in 
the  uterus  and  broad  ligament  is  now  closed  with  a  continuous  catgut 
suture.  When  both  tubes  and  ovaries  are  excised,  some  operators 
advise  a  supravaginal  amputation  of  the  uterus,  in  order  to  remove 
all  the  infected  structures,  and  likewise  prevent  the  adhesions  which 
necessarily  form  between  the  intestines  and  the  raw  posterior  surface 
of  the  uterus.  If  the  ovaries  are  normal  they  should  be  allowed  to 
remain,  the  ligature  securing  the  ovarian  artery  being  placed  to  the 
inner  side  of  the  ovary.  Occasionally  only  the  outer  two-thirds  of  the 
tube  will  require  removal,  the  mucous  membrane  of  the  remaining 
portion  being  sutured  to  the  peritoneum,  in  order  to  allow  the  passage 

of  ova.     In  cases  of  sterility  due  to 

closure  of  the  abdominal  ostium, 

salpingostomy  may  be  performed 

if  the  tube  is  fairly  healthy.     The 

outer  end  of  the  tube  is  opened, 

and  its  mucous  membrane  sutured 

to  the  peritoneum   with  catgut. 

When  the  tubes  are  neither  seri- 

FiG.  539.— Methods  of  ligation  in  sal-  ously    altered    in    structure  nor 

Sr/ofrbringamen'?;  SftheTeX  occluded,  but  simply  prolapsed 

ligation  of  the   individual   vessels,   with  ^nd  adherent,  the  adhesions  may 

wedge-shaped  amputation  of  the  tube;  the  1    +V«       f    k 

wound  in  the  uterus  and  broad  ligament  is  be  separated,  ailCl  tne  tUDeS  re- 
closed  with  a  continuous  catgut  suture.         taiued  in  their  normal  position  by 

shortening  the  infundibulo-pelvic  ligaments,  or  by  performing  one 
of  the  operations  for  retroversion.  Drainage  is  rarely  needed  after 
operations  for  salpingitis,  but  may  be  required  for  continued  oozings 
from  adhesions,  or  in  cases  in  which  the  infection  is  active.  The 
best  drain  for  these  cases  is  vaselinized  gauze,  gaining  exit  through 
the  posterior  vaginal  fornix. 

Tuberculous  salpingitis  is  the  most  frequent  form  of  genital 
tuberculosis;  it  is  usually  bilateral  and  secondary  to  tuberculosis 
elsewhere,  but  may  be  primary,  the  bacilli  being  conveyed  to  the 
tubes  from  the  endometrium  or  peritoneum,  or  through  the  blood  or 
lymph  vessels.  The  tubes  are  usually  distended  with  pus  or  cheesy 
material,  and  give  rise  to  symptoms  similar  to  those  of  other  forms 
of  salpingitis.  The  condition  may  be  suspected  if  there  is  tuber- 
culosis elsewhere  in  the  body,  if  evidences  of  other  forms  of  infec- 
tion are  absent,  if  there  is  an  encysted  ascites,  and  if  on  bimanual 


GENITAL   ORGANS  961 

examination  the  tubes  arc  nodular  and  only  slightly  sensitive. 
Tubercle  bacilli  have  been  found  in  the  discharge  from  the  uterus. 
The  trcatmoit  is  sali)ingo-oophorectomy. 

Neoplasms  of  the  tubes  include  papilloma,  carcinoma,  fibro- 
myoma,  lipoma,  dermoids,  lymphangioma,  enchondroma,  and  sar- 
coma. These  growths  are  rarely  recognized  until  after  abdominal 
section  for  their  removal. 

Extrauterine  or  ectopic  pregnancy  occurs  about  once  to  every 
500  intrauterine  pregnancies.  The  causes  are  not  clear,  but  it  is 
supposed  to  be  due  to  an  unusually  large  ovum,  or  to  conditions 
which  narrow,  elongate,  or  twist  the  tube,  or  destroy  the  cilia  of  the 
mucosa,  thus  interfering  with  its  peristalsis.  Among  these  condi-, 
tions  are  salpingitis,  peritoneal  adhesions,  neoplasms,  stenosis  or 
atresia,  and  tubal  diverticulum.  According  to  its  situation  the 
pregnancy  may  be  (i)  tubal,  usually  in  the  free  portion  {tubal  proper) , 
but  occasionally  in  that  part  embraced  by  the  uterine  wall  (tubo- 
uterine  or  interstitial),  or  between  the  tube  and  the  ovary  (tubo- 
ovarian);  (2)  ovarian,  which  is  very  rare;  or  (3)  abdominal,  the 
ovum  being  fertihzed  and  developing  in  the  peritoneal  cavity  {pri- 
mary abdominal  pregnancy),  an  event  which  many  believe  cannot 
occur,  or  escaping  from  one  of  the  previously  mentioned  situations 
and  continuing  its  growth  in  the  abdominal  cavity  {secondary 
abdominal  pregnancy) .  It  is  possible  for  an  enlarging  ovum  in  the 
uterine  cavity  to  break  through  an  old  scar  in  the  uterus  and  thus 
become  abdominal. 

Pathology. — In  tubal  pregnancy  the  walls  of  the  tube  at  first 
thicken,  and  later  become  thin  and  weak  owing  to  distention  and  to 
the  ingrowth  of  chorionic  villi.  The  abdominal  ostium  narrows,  and 
finally  closes  about  the  eighth  week.  Prior  to  this  time  the  ovum 
may  be  extruded  from  the  fimbriated  extremity,  constituting  a 
tubal  abortion.  If  this  does  not  occur,  the  tube  usually  ruptures, 
most  often  between  the  eighth  and  twelfth  weeks,  either  into  the 
peritoneal  cavity  or  between  the  layers  of  the  broad  ligament. 
In  the  former  event  the  hemorrhage  may  be  quickly  fatal,  or,  if 
the  rupture  is  small,  the  bleeding  may  be  checked  by  the  bulging 
ovum  and  a  new  sac  be  formed,  which  in  turn  is  ruptured,  either 
causing  a  fatal  hemorrhage,  or  again  forming  a  new  sac.  In  rupture 
between  the  layers  of  the  broad  hgament,  the  bleeding  is  limited 
and  seldom  directly  fatal,  unless  the  broad  ligament  becomes  over- 
distended  and  also  gives  way.  Hemorrhage  is  frequently  the  result 
of  perforation  of  the  tube  by  developing  vilh,  instead  of  rupture.  In 
interstitial  pregnancy  rupture  is  often  postponed  until  the  end  of  the 


962  MANUAL    OF    SURGERY 

fourth  month,  and  occasionally  takes  place  into  the  uterine  cavity. 
The  ovum  develops  normally  until  the  first  hemorrhage,  when  the 
fetus  usually  dies;  if  the  patient  survives,  the  ovum  may  be  ab- 
sorbed or  converted  into  a  tubal  mole,  or  it  may  cause  suppuration. 
Occasionally  the  fetus  survives,  and,  particularly  in  extraperitoneal 
ruptures,  may  reach  even  full  development.  If  the  fetus  dies  after 
it  has  attained  a  large  size,  it  may  mummify,  calcify  (litlwpedion), 
be  converted  into  adipocere,  or  suppurate,  the  resulting  abscess 
breaking  into  the  peritoneal  cavity,  rectum,  vagina,  bladder,  or 
through  the  abdominal  wall.  It  has  been  asserted  that  the  placenta 
may  continue  to  develop  after  the  death  of  the  fetus,  but  this  is 
doubtful.  When  the  ovum  is  impregnated,  the  endometrium  forms 
a  decidua  which  is  often  expelled  at  the  time  of  the  tubal  abortion 
or  rupture.  Bilateral  ectopic  gestation,  coincident  intra-  and  ex- 
trauterine pregnancy,  and  twin  or  triplet  extrauterine  pregnancy 
have  all  been  observed. 

Symptoms  are  often  absent  until  the  time  of  rupture.  There  is 
frequently  a  history  of  sterility  or  salpingitis,  followed  by  amenorrhea 
and  the  early  signs  of  pregnancy.  Tubal  abortion  or  rupture  is 
announced  by  severe,  sharp,  often  excruciating  pain,  with  shock  or 
syncope,  and  the  symptoms  of  internal  hemorrhage.  At  this  time 
there  will  likely  be  metrorrhagia  with  discharge  of  the  uterine  decidua, 
either  in  shreds  or  as  a  cast  of  the  uterus.  If  the  patient  survives, 
other  attacks  usually  follow.  If  the  gestation  goes  to  term,  spurious 
labor  occurs,  and  the  fetus  dies  and  undergoes  the  changes  mentioned 
above.  The  uterus  is  enlarged,  the  cervix  soft,  and  prior  to  rup- 
ture the  tube  is  slightly  distended.  Subsequent  to  rupture  the  local 
signs  are  those  of  pelvic  hematocele  or  hematoma  (q.v.).  The 
conditions  resembling  ectopic  gestation  may  be  grouped  under  five 
headings:  (i)  Uterine  pregnancy  (particulary  when  compUcated 
by  one  of  the  conditions  mentioned  below),  pregnancy  in  a  bicornate 
uterus,  and  spurious  pregnancy;  (2)  any  condition  giving  rise  to  a 
pelvic  mass,  notably  salpingitis,  and  ovarian  cyst  with  twisted 
pedicle;  (3)  conditions  associated  with  acute  pain,  such  as  appendi- 
citis and  other  acute  intraabdominal  diseases;  (4)  conditions  associ- 
ated with  metrorrhagia,  especially  abortion,  which  is  the  affection 
most  often  mistaken  for  ectopic  pregnancy  by  the  general  practi- 
tioner, because  both  are  preceded  by  amenorrhea,  and  in  each  a 
decidual  membrane  is  discharged;  and  (5)  intraabdominal  bleeding 
from  causes  other  than  extrauterine  pregnancy,  e.g.,  ruptured 
ovarian  hematoma  (q.v.)  and  ruptured  varix  of  the  broad  ligament 
(cf.  "Pelvis  Hematocele  and  Hematoma").     In  the  last  group  the 


GENITAL   ORGANS  963 

exact  diagnosis  is  seldom  made  before  operation.  It  is  too  early 
to  make  a  dogmatic  statement  as  to  the  value  of  Abderhalden's 
scro-test  for  pregnancy,  including  the  ectopic  variety.  The  X-ray 
might  i^rove  of  service  in  late  cases,  i.e.,  after  the  fourth  or  the  sixth 
month. 

The  treatment  In^fore  rupture  is  abdominal  section  and  removal  of 
the  affected  tube,  providing  the  diagnosis  can  be  made  at  this  time. 
If  rupture  occurs  into  the  peritoneal  cavity,  the  abdomen  should  be 
opened  immediately,  the  tube  and  ovary  on  the  affected  side  removed 
as  quickly  as  possible,  liquid  and  clotted  blood  washed  from  the 
abdominal  cavity  with  salt  solution,  the  abdomen  closed  without 
drainage,  and  the  patient  treated  for  shock  and  acute  anemia.  To 
allow  the  effused  blood  to  remain  in  the  peritoneal  cavity  causes 
autointoxication,  intestinal  paresis,  adhesions,  and  predisposes  tc 
peritonitis.  In  interstitial  pregnancy  it  may  be  necessary  to  perform 
hysterectomy  in  order  to  control  the  bleeding.  When  rupture  occurs 
between  the  layers  of  the  broad  ligament,  if  the  hematoma  is  small 
and  there  are  no  constitutional  symptoms  of  hemorrhage,  the  patient 
should  be  put  in  bed,  an  ice  cap  applied  to  the  lower  abdomen, 
and  expectant  treatment  adopted,  with  the  hope  that  absorption 
will  occur.  If  the  hematoma  is  large,  or  if  constitutional  symptoms 
of  hemorrhage  are  present,  operation  is  indicated.  If  a  hematoma 
treated  expectantly  suppurates,  it  should  be  opened  through  the 
vagina  and  drained.  In  advanced  extrauterine  pregnancy,  if  the  fetus 
is  aUve,  operation  may  be  delayed  until  just  short  of  term,  with  the 
hope  of  saving  the  life  of  the  child.  The  entire  fetal  sac  should  be 
removed  if  possible;  when  this  is  inadvisable,  it  should  be  sutured 
to  the  skin  and  drained.  The  placenta  should,  however,  be  removed 
if  such  can  be  done  with  safety.  Often  the  fear  of  a  fatal  hemorrhage 
will  cause  the  operator  to  tie  the  cord  close  to  the  placenta  and  allow 
it  to  come  away  at  a  later  period.  In  advanced  cases  in  which  the 
child  is  dead,  the  entire  sac  should  be  removed  or  drained,  according 
to  indications. 

THE  OVARY 

The  ovaries  may  be  absent  or  rudimentary,  and  accessory 
ovaries  have  occasionally  been  observed. 

The  ovary  may  be  displaced  by  changes  in  the  position  of  the 
Fallopian  tube  or  uterus,  by  tumors,  and  by  peritoneal  adhesions.  It 
may  be  fixed  at  a  high  level,  thus  corresponding  to  an  undescended 
testicle,  or  it  may  be  found  in  the  sac  of  a  hernia.  The  most  impor- 
tant displacement  is  prolapse  of  the  ovary  downward  into  Douglas's 


964  MANUAL   OF    SURGERY 

pouch.  It  may  be  caused  by  relaxation  of  the  ligaments,  especially 
after  child-birth,  increased  intraabdominal  pressure,  retrodeviations 
of  the  uterus,  salpingitis,  and  by  any  condition  which  increases  the 
weight  of  the  ovary,  e.g.,  neoplasms  and  inflammatory  affections. 
The  symptoms  are  those  of  the  causative  lesion,  with  those  of  pressure 
on  the  ovary,  viz.,  dyspareunia,  painful  defecation,  and  pain  on  stand- 
ing or  walking.  The  diagnosis  is  made  by  bimanual  examination. 
The  treatment  is  that  of  the  condition  which  has  caused  the  prolapse. 
When  due  simply  to  relaxation  of  the  ligaments,  without  serious 
changes  in  the  ovary,  the  infundibulo-pelvic  ligament  may  be  short- 
ened, or  the  ovary  sutured  to  a  fixed  portion  of  the  broad  ligament. 

Ovaritis,  or  inflammation  of  the  ovary,  may  be  acute  or  chronic. 

Acute  ovaritis  may  occur  in  mumps  or  other  acute  infectious  fevers, 
and  after  the  ingestion  of  metallic  poisons,  such  as  arsenic  and  phos- 
phorus, but  it  is  most  frequently  secondary  to  salpingitis,  hence  due 
to  the  same  causes.  The  ordinary  phenomena  of  inflammation  are 
present.  The  disease  may  terminate  in  resolution  or  in  abscess 
formation,  or  it  may  become  chronic.  The  symptoms  are  those  of  the 
salpingitis  with  which  it  is  usually  associated;  pain,  however,  is 
much  more  intense.  Pelvic  peritonitis  and  the  constitutional 
symptoms  of  sepsis  are  present  in  the  severer  forms.  Occasionally 
the  enlarged  ovary  may  be  mapped  out  on  bimanual  examination, 
but  as  a  rule  all  that  can  be  felt  is  a  sensitive  mass  behind  or  to  the  side 
of  the  uterus,  consisting  of  tube,  ovary,  and  pelvic  exudate.  The 
treatment  is  that  of  acute  salpingitis. 

Chronic  ovaritis  may  follow  the  acute  form,  or  it  may  be  caused  by 
repeated  or  continued  congestion  the  result  of  excessive  venery, 
menstrual  suppression,  displacements  of  the  uterus,  pelvic  tumors,  or 
inflammatory  affections  of  adjacent  organs.  In  the  early  stages  the 
ovaries  are  enlarged  and  firm  {hyperplastic  ovaritis)  and  are  apt  to 
prolapse  behind  the  uterus.  At  a  later  period  rupture  of  the  Graafian 
follicles  is  hindered  by  the  thickened  tunica  albuginea  and  the  ovary 
is  filled  with  small  cysts  {cystic  ovaries) .  In  the  final  stages  the  con- 
nective tissue  contracts  and  renders  the  ovary  small,  hard,  and 
fissured  {cirrhosis  of  the  ovaries).  The  symptoms  are  pain  in  the 
region  of  the  ovary,  increased  by  walking,  defecation,  coitus,  or 
jolting  and  worse  at  the  menstrual  periods,  which  are  apt  to  be 
profuse  and  prolonged.  Sterility  is  common,  and  when  the  ovaries 
become  cirrhotic,  there  may  be  amenorrhea.  Hysteria,  neurasthe- 
nia, and  various  reflex  neuroses  are  frequent  complications.  The 
diagnosis  is  made  by  bimanual  examination,  which  is  often  rendered 
easier  by  descent  of  the  ovaries. 


GENITAL    ORGANS 


965 


The  treatment  is  removal  of  the  cause  of  congestion  if  possible, 
attention  to  the  general  health,  the  application  of  iodin  to  the  vaginal 
vaults,  support  of  the  ovary  with  a  tampon,  and  hot  vaginal  douches. 
If  these  measures  fail  to  give  rehef,  the  ovaries  should  be  removed. 
Excision  of  the  most  diseased  portion  of  the  ovary  by  a  wedge- 
shaped  incision  followed  by  suture,  puncturing  of  cysts,  and  shorten- 
ing of  the  infundibulo-pelvic  ligament  may  be  beneficial,  but  such 
measures  are  uncertain. 

Tuberculosis  of  the  ovary  is  almost  always  secondary  to  tubercu- 
losis of  the  Fallopian  tube  or  peritoneum,  and  the  infected  ovary 
should  be  removed  when  the  disease  in  these  situations  is  attacked. 

Atrophy  of  the  ovary  prior  to  the  menopause  may  be  caused  by  the 
pressure  of  tumors,  chronic  inflammation,  ovarian  hemorrhage, 
varicocele  of  the  broad  ligament, 
superinvolution  of  the  uterus, 
obesity,  diabetes,  myxedema, 
hypopituitarism,  and  by  certain 
neuroses  and  exhausting  dis- 
eases. There  is  amenorrhea 
with  sterility.  The  treatment  is 
directed  to  the  cause. 

Ovarian  hemorrhage  may 
take  place  into  the  follicles  Or 
stroma  of  the  ovary,  as  the  re- 
sult of  congestion  or  inflamma- 
tion, and  is  called  ovarian  apo- 
plexy. When  the  hemorrhage 
is  diffuse,  the  whole  organ  may 
be  converted  into  a  blood  sac  {hematoma  of  the  ovary) ,  which  may 
rupture  into  the  peritoneal  cavity,  resulting  in  the  formation  of  a 
hematocele,  or  occasionally  causing  death  from  hemorrhage.  These 
cases  are  usually  mistaken  for  ectopic  pregnancy.  Small  hemor- 
rhages are  of  little  importance,  but  profuse  bleeding  demands  ab- 
dominal section  and  removal  of  the  ovary. 

Tumors  of  the  ovary  include  the  fibroma,  myoma,  fibromyoma, 
sarcoma,  papilloma,  carcinoma,  and  endothelioma.  All  of  these 
growths  are  comparatively  rare,  and  the  malignant  are  more  frequent 
than  the  benign  varieties.  Carcinoma  is  usually  secondary,  but  may 
be  primary,  and  is  commonly  of  the  medullary  variety.  Sarcoma 
(Fig.  540)  is  the  most  frequent  neoplasm,  it  is  usually  of  the  spindle- 
celled  variety,  and  may  occur  in  childhood.  The  ovary  rapidly 
enlarges,  sometimes  reaching  an  enormous  size,  but  retains  its  shape 


Fig.  540.- 


-Showing    outline 
right  ovary. 


of 


966 


MANUAL   OF   SURGERY 


and  presents  a  smooth  surface.  Ascites  is  common  and  the  other 
ovary  is  usually  involved.  The  symptoms  of  tumors  are  those  of 
cysts  of  the  ovary.  Rapid  growth  and  ascites  always  suggest 
malignancy.  The  treatment  is  removal  of  the  ovary;  the  opposite 
organ  should  always  be  excised  in  sarcoma,  as  it,  too,  is  generally 
sarcomatous. 

Cysts  of  the  ovary  and  parovarium  may  be  found  at  any  time  of 
life,  but  are  most  frequent  between  the  ages  of  twenty  and  fifty. 
The  etiology  is  obscure,  some  are  undoubtedly  the  result  of  inflam- 
mation. Fig.  541  shows  the  areas  in  and  about  the  ovary  in  which 
cysts  develop.  The  hydatid  of  Morgagni,  representing  the  closed 
extremity  of  Miiller's  canal,  is  a  small  cyst  which  may  be  regarded 
as  normal. 

Cysts  of  the  oophoron,  or  egg  bearing  portion  of  the  ovary,  are 
of  several  varieties.     Simple  or  follicular  cysts  {hydrops  folliculorum) 


HYDATID  OF 
MORGAGNI    OR 
CLOSED  END  OF 
-MULLER5  DUCT 


Fig.   541. — Diagram  showing  structures  from  which  cysts  arise. 


are  dilated  Graafian  follicles;  they  are  unilocular,  multiple,  and  usu- 
ally bilateral  and  of  small  size,  but  occasionally  may  be  as  large  as, 
or  larger,  than  a  man's  head.  The  cyst  replaces  the  ovary  and  has  a 
thin  wall  and  serous  contents.  Cysts  of  the  corpus  luteum  are  uniloc- 
ular and  rarely  larger  than  an  orange.  Microscopic  examination 
of  the  wall  demonstrates  the  bud-like  papillae  characteristic  of  the 
corpus  luteum.  Cystadenoma  {glandular  proliferating  cyst)  springs 
from  the  parenchyma  of  the  ovary  and  may  attain  an  enormous 
size.  It  is  always  multilocular,  and  sometimes  resembles  a  honey- 
comb on  section,  the  walls  being  made  up  of  altered  glandular  tissue. 
Unilocular  cysts  of  this  variety  are  due  to  absorption  of  the  partition 
walls.  The  contents  may  be  thin  or  gelatinous,  and  hght  yellow, 
green,  purple,  or  black  in  color;  the  contents  of  the  different  locuH 


GENITAL   ORGANS  967 

ill  the  same  cyst  usually  vary  in  color  and  consistency.  Occasionally 
the  cysts  contain  papillary  growths.  Dermoids  containing  epiblastic 
derivatives,  such  as  hair,  teeth,  etc.,  occur  in  the  ovaries,  as  well  as 
teratomatii,  which  contain  tissues  from  all  the  blastodermic  layers. 
Dermoids  have  dense  walls,  and,  because  of  their  weight,  are  more 
prone  to  rotate  on  the  pedicle  than  other  cysts.  Rupture  or  aspira- 
tion of  a  dermoid  may  result  in  peritonitis,  owing  to  the  irritating 
character  of  its  contents. 

Cysts  of  the  paroophoron,  or  hilum  of  the  ovary,  which  consists  of 
connective  tissue  and  blood  vessels,  are  usually  unilocular,  do  not 
affect  the  shape  of  the  ovary  unless  of  large  size,  burrow  between  the 
layers  of  the  mesosalpinx  and  broad  ligament,  and  generally  contain 
papillomatous  masses  (proliferating  papillary  cysts),  which  may  spread 
to  and  infect  the  peritoneum,  causing  ascites  and  the  growth  of 
papillomata  all  over  the  abdominal  cavity. 

Cysts  of  the  parovarium  arising  in  the  vertical  tubes  are  generally 
unilocular,  tilled  with  a  clear  fluid  of  low  specific  gravity,  and  burrow 
between  the  layers  of  the  broad  ligament.  They  neither  contract 
adhesions  nor  suppurate,  and  never  occur  before  puberty.  The 
ovary  is  attached  to  one  side  of  the  cyst,  over  which  is  stretched  the 
Fallopian  tube.  Cysts  of  Gartner 's  duct  may  project  down  into  the 
vagina.  Cysts  of  KoheWs  tubes  are  small,  pedunculated,  and  of 
no  clinical  importance. 

Tubo -ovarian  cysts  are  retort-shaped  and  due  to  fusion  of  the 
tube  with  an  ovarian  cyst,  or  to  the  communication  of  the  tube  with 
an  abnormal  peritoneal  investment  of  the  ovary  [ovarian  hydrocele) . 
In  some  of  these  cases  the  fluid  is  evacuated  through  the  tube  into 
the  uterus. 

The  symptoms  of  ovarian  cysts  are  mainly  those  of  pressure, 
such  as  have  been  listed  under  libromyomata  of  the  uterus,  and  those 
due  to  accidental  complications.  Menstruation  may  be  unaffected, 
or  there  may  be  amenorrhea  from  destruction  of  the  ovaries,  or 
menorrhagia  from  pressure  on  the  pelvic  veins.  When  the  tumor 
is  very  large  it  interferes  with  respiration,  presses  on  the  stomach 
and  intestines,  causing  emaciation  and  a  peculiar  facial  expression 
{fades  ovariana),  and  leads  to  umbilical  hernia,  dilated  superficial 
veins,  and  to  the  formation  of  lineae  albicantes.  Sometimes  the 
breasts  enlarge,  become  pigmented  and  painful,  and  secrete  col- 
ostrum. Death  is  usually  the  result  of  exhaustion,  uremia,  or  some 
complication. 

The  complications  are  ascites,  inflammation  (adhesions,  suppura- 
tion), torsion  of  the  pedicle  (hemorrhage,  gangrene),  and  rupture. 


968 


MANUAL   OF   SURGERY 


Ascites  is  most  frequent  in  malignant  growths,  fibromata,  and 
papillomatous  cysts. 

Inflammation,  causing  symptoms  of  localized  peritonitis,  may 
be  caused  by  tapping,  or  by  infection  derived  from  the  tubes,  bladder, 
intestines,  or  from  the  blood  or  lymph  vessels.  Circumscribed  or 
universal  adhesions  are  thus  formed  between  the  cyst  wall  and 
adjacent  structures,  which  may  be  vascular  enough  to  keep  the  cyst 
alive,  even  after  it  has  been  separated  from  its  pedicle.  Suppuration 
is  most  frequent  in  dermoids,  and  is  manifested  by  the  signs  of  a 

severe  localized  peritonitis,  with 
the  constitutional  symptoms  of 
sepsis.  The  treatment  of  these 
cases  is  immediate  removal  of  the 
cyst,  or,  when  this  is  impossible, 
suture  of  the  cyst  to  the  addominal 
wall  and  drainage.     Left  to  itself 


Pig.  542.  Pig.  543. 

Pig.  542. — Area  of  dulness  in  ascites  (shaded)  and  in  ovarian  cyst  (dotted  line) 
when  the  patient  is  recumbent.  Note  that  the  former  is  symmetric,  with  a  concave 
upper  border;  that  the  latter  is  asymmetric  and  convex.  The  shape  of  the  dull  area  in 
ascites  changes  with  the  position  of  the  patient,  that  of  a  cyst  is  always  the  same. 

Pig.  543. — Lateral  view  of  abdomen  in  ascites.  Dotted  line  indicates  ovarian  cyst 
and  its  effect  on  the  profile  of  the  abdomen.  Note  that  in  ascites  the  greatest  circum- 
ference is  at,  in  ovarian  cvst  below,  the  umbilicus. 


the  abscess  may  rupture  into  the  peritoneal  cavity,  into  one  of  the 
hollow  viscera,  into  the  vagina,  or  externally  through  the  abdominal 
wall. 

Torsion  of  the  pedicle  is  most  apt  to  occur  when  the  pedicle  is 
long,  when  the  tumor  is  small  and  heavy,  e.g.,  dermoids,  and  during 
pregnancy.  If  the  twist  takes  place  slowly,  the  cyst  may  be  gradu- 
ually  separated  from  its  pedicle  and  be  nourished  by  adhesions. 
When  the  torsion  is  acute  and  tight,  strangulation  ensues,  the  cyst 
increasing  in  size  from  effusion  of  blood  and  later  becoming  gan- 
grenous. There  are  severe  pain,  shock,  rigidity  of  the  abdominal 
muscles,  and  symptoms  of  internal  hemorrhage  if  there  is  much  loss 


GENITAL   ORGANS  969 

of  blood.  Intracystic  licmorrJiage.  causing  sudden  enlargement  of 
the  tumor,  may  follow  also  injury  or  tapping,  or  it  may  arise  spon- 
taneously from  dilated  veins  or  papillomatous  masses.  Torsion  of 
the  pedicle  calls  for  immediate  removal  of  the  cyst. 

Rupture  of  the  cyst  may  follow  traumatism  of  any  character, 
twisting  of  the  pedicle,  or  simple  overdistention.  It  is  most  prone 
to  occur  in  the  thin-walled  parovarian  cyst.  The  swelling  suddenly 
diminishes  in  size  or  disappears,  and  free  fluid  is  found  in  the  abdo- 
men. This  may  be  rapidly  absorbed,  leading  to  free  sweating  and 
the  passage  of  large  quantities  of  urine.  In  rare  instances  symp- 
toms of  intraabdominal  hemorrhage  appear.  The  passage  of 
serous  fluids  into  the  peritoneal  cavity  does  no  harm  unless  the  cyst 
is  inflamed.  Rupture  of  a  dermoid  is  generally  followed  by  periton- 
itis; if  the  cyst  be  papillomatous,  these  growths  may  be  widely 
implanted  throughout  the  abdominal  cavity.  Immediate  opera- 
tion is  not  imperative  for  rupture  of  the  cyst,  unless  it  be  dermoid 
or  papillary  in  nature,  or  unless  there  be  symptoms  of  internal 
hemorrhage  or  peritonitis. 

The  diagnosis  of  small  cysts  is  made  by  bimanual  examination. 
Inflammatory  masses  are  fixed,  more  painful,  intimately  connected 
with  the  uterus,  and  are  preceded  by  a  history  of  infection.  Solid 
tumors  are  much  harder,  are  often  accompanied  by  ascites,  and 
grow  rapidly  if  malignant.  The  presence  or  absence  of  fluctuation 
depends  upon  the  thickness  of  the  cyst  wall,  the  number  of  locuh, 
and  the  contents  of  the  cyst.  Dermoids  have  a  doughy  feel  and  the 
X-ray  may  show  the  presence  of  bone.  A  large  cyst  ascends  into 
the  abdomen,  pushes  the  uterus  to  one  side,  and  elongates  the 
vagina;  it  may  be  mistaken  for  conditions  like  ascites,  pregnancy, 
hematometra,  hydramnios,  and  distended  bladder.  In  ascites,  when 
the  patient  is  recumbent,  the  flanks  bulge  and  are  dull  on  per- 
cussion, while  the  central  portion  of  the  abdomen  is  tympanitic 
(Fig.  542) ;  when  the  pelvis  is  elevated  the  area  of  dulness  in  the 
loins  is  increased;  when  the  patient  turns  on  one  side  the  upper 
flank  is  tympanitic;  the  greatest  circumference  of  the  abdomen  is 
at  the  umbilicus,  not  below  as  in  ovarian  cyst  (Fig.  543) ;  the  fluctua- 
tion wave  is  very  distinct  and  extends  all  over  the  abdomen;  the 
vagina  is  not  lengthened,  indeed  may  be  shortened  from  descent  of 
the  uterus  and  bulging  of  the  fornices;  the  uterus  is  in  the  midline 
and  freely  movable;  and  disease  of  the  heart,  liver,  or  kidneys  may 
be  found.  In  ovarian  cyst  the  patient  may  have  noticed  that  the 
swelling  was  at  first  unilateral.  The  possibility  of  making  a  diag- 
nosis of  intraabdominal  tumors  and  cysts  with  the  X-ray,  after  the 


97°  MANUAL   OF   SURGERY 

injection  of  air  into  the  peritoneal  cavity,  is  referred  to  in  the  section 
on  "Cirrhosis  of  the  Liver."  In  localized  peritoneal  ejfiisions,  such 
as  are  most  often  seen  in  connection  with  tuberculous  peritonitis, 
the  diagnosis  may  be  impossible  without  exploratory  incision. 
A  pregnant  uterus  is  more  central,  less  fluctuating,  and  is  associated 
with  softening  of  the  cervix,  amenorrhea,  and  the  positive  signs  of 
pregnancy;  the  parts  of  the  fetus  may  be  recognized,  and  the  growth 
is  more  rapid  than  ovarian  cyst.  X-ray  examination  may  show 
the  fetus  after  the  fourth  month  of  pregnancy.  Abderhalden 's 
sero-diagnosis  of  pregnancy  also  may  be  considered.  In  hemato- 
metra  the  menses  are  absent,  atresia  of  the  genital  canal  is  present, 
the  tumor  is  central  and  formed  by  the  uterus,  and  the  menstrual 
molimina  appear  each  month.  Hydramnios  will  show  the  signs 
of  pregnancy.  A  distended  bladder  will  collapse  upon  the  intro- 
duction of  a  catheter. 

The  treatment  is  ovariotomy,  or  removal  of  the  cyst.  Tapping 
is  never  indicated,  unless  the  patient 's  condition  forbids  abdominal 
section.  A  coexisting  pregnancy  is  not  a  contraindication  to 
operation,  indeed,  as  complications  are  likely  to  arise  at  this  time 
and  during  labor,  it  makes  operation  more  urgent.  Ovariotomy 
is  performed  through  a  median  abdominal  incision  below  the  umbili- 
cus. A  hand  is  introduced  into  the  abdomen  and  any  light  ad- 
hesions broken,  care  being  taken  not  to  mistake  the  peritoneum 
for  the  cyst  wall.  The  cyst  is  punctured  with  a  trocar  to  which  a 
rubber  tube  is  attached,  the  contents  draining  into  a  bucket  at  the 
side  of  the  table.  An  assistant  makes  pressure  on  the  abdominal 
wall  to  keep  it  closely  applied  to  the  cyst,  which  is  seized  with  for- 
ceps and  drawn  from  the  abdomen  as  it  collapses.  Adhesions  to 
the  deeper  parts,  if  present,  may  now  be  separated,  or  tied  and  cut, 
according  to  their  nature,  oozing  from  large  raw  surfaces  being 
controlled  by  pads  soaked  in  hot  water,  or  by  sutures  or  gauze 
packing.  The  pedicle,  consisting  of  the  broad  ligament,  the  ovarian 
ligament,  and  the  Fallopian  tube,  and  containing  the  anastomosis 
between  the  ovarian  and  uterine  arteries,  is  transfixed  and  ligated 
as  in  salpingo-oophorectomy,  and  divided  about  one-half  inch 
beyond  the  ligature.  The  other  ovary  should  be  removed  if  it  is 
diseased,  if  the  woman  is  near  the  menopause,  or  if  the  ovarian 
growth  is  malignant  or  papillomatous.  In  dermoids,  papillomatous 
cysts,  and  in  cysts  which  are  inflamed  or  suppurating,  the  growth 
should  be  removed  without  tapping  whenever  possible.  Intra- 
ligamentary  cysts  are  enucleated  after  incising  the  layers  of  the 
broad  ligament,  and  usually  after  tying  the  ovarian  and  occasionally 


GENITAL   ORGANS  97 1 

the  uterine  artery.  The  raw  cavity  left  is  closed  by  sutures,  and 
sometimes  drained  throu<!;h  the  vagina.  'J1ie  abdominal  wound 
is  closed  in  the  usual  manner.  When  adhesions  are  dense  and 
universal,  particularly  if  the  condition  of  the  patient  is  poor,  the 
cyst  may  be  sutured  to  the  abdominal  wound  and  drained  {mar- 
supialization). The  mortality  of  uncomplicated  ovariotomy  is 
about  5  per  cent. 

PELVIC  PERITONEUM  AND  CONNECTIVE  TISSUE 

Pelvic  peritonitis  is  usually  secondary  to  salpingitis,  but  may 
follow  inflammation  or  perforation  of  any  of  the  pelvic  organs,  or 
the  leakage,  through  the  tube  into  the  peritoneal  cavity,  of  fluid 
which  has  been  injected  into  the  uterus.  It  may  be  caused  also 
by  the  irritation  of  pelvic  tumors,  and  is  a  part  of  a  generalized 
peritonitis  caused  by  lesions  of  any  of  the  abdominal  viscera.  The 
symptoms  are  pain  and  tenderness  in  the 
lower  part  of  the  abdomen,  rigidity  of  the 
overlying  muscles,  constipation,  tympany, 
vomiting,  irritability  of  the  bladder,  fever, 
and  a  rapid,  wiry  pulse.  The  patient  lies 
•on  the  back  with  the  knees  drawn  up.  The 
vagina  is  hot  and  dry,  the  vaginal  fornices 
exceedingly  tender,  and  the  pelvis,  particu-       p^^  _pp    jj^^j^^a- 

larly  the  pouch  of  Douglas,  filled  with  exudate    tion  from  pelvic  peritonitis; 

/T^.'  \  1  •    1  111  r^  CC,  induration  from  pelvic 

(rig.  544),  which  may  be  hard  or  soft,  ac-    cellulitis. 
cording  to  the  presence  or  absence  of  puS. 

The  treatment  of  acute  pelvic  peritonitis  due  to  salpingitis  is 
rest  in  bed,  fluid  diet,  an  ice  bag  to  the  lower  abdomen,  saline  laxa- 
tives, hot  vaginal  douches,  sedatives  for  pain,  and  stimulants  if 
needed.  If  suppuration  occurs  and  fluctuation  can  be  detected 
in  Douglas's  pouch,  the  abscess  should  be  opened  in  this  situation 
and  a  vaselinized  gauze  drain  inserted,  particularly  if  the  condition 
of  the  patient  is  poor.  Even  after  an  abscess  has  beeif  drained 
through  the  vagina,  it  will  usually  be  necessary  to  remove  the  tubes 
and  ovaries  at  a  later  period,  when  the  condition  of  the  patient  has 
improved.  In  all  other  cases  abdominal  section  with  removal  of 
the  cause  of  trouble  is  the  proper  treatment. 

Chronic  pelvic  peritonitis  is  adhesions  and  organizing  exudate 
following  the  acute  form,  and  results  in  displacements  of  the  uterus 
and  appendages.-  Its  treatment  has  been  considered  with  these 
subjects  and  with  salpingitis. 


972  MANUAL   OF   SURGERY 

Pelvic  cellulitis  is  inflammation  of  the  connective  tissue  of  the 
pelvis,  and  may  exist  about  the  bladder,  uterus,  vagina,  or  rectum, 
or  in  any  of  the  pelvic  ligaments.  It  is  comparatively  rare,  and 
almost  always  associated  with  pelvic  peritonitis.  Parametritis  is 
that  form  involving  the  connective  tissue  of  the  broad  ligaments.  It 
is  usually  of  puerperal  origin,  the  infection  enteiing  through  lacera- 
tions or  abrasions  of  the  endometrium,  cervix,  or  vagina,  but  it 
may  be  caused  also  by  inflammation  of,  or  opeiations  on,  any  of 
the  pelvic  organs.  The  pathology  is  that  of  cellulitis  elsewhere. 
Suppuration  is  the  common  result,  the  abscess  rupturing  into  the 
vagina,  rectum,  or  bladder,  or  through  the  abdominal  wall  above 
Poupart's  ligament,  through  one  of  the  hernial  canals,  or  through 
the  sciatic  or  obturator  foramen;  occasionally  it  opens  into  the 
peritoneal  cavity.  The  exudate  may  be  wholly  absorbed,  or  it 
may  organize  and  result  in  chronic  pelvic  congestion,  displacements 
of  the  uterus,  or  stricture  of  the  rectum. 

The  symptoms  in  the  mildest  cases  are  those  of  the  causative 
salpingitis  or  endometritis.  In  the  severe  form  there  are  chills, 
fever,  and  the  general  symptoms  of  septicemia.  Locally  there  are 
pain,  metrorrhagia,  and  often  irritabiUty  of  the  bladder  or  bowel, 
when  the  connective  tissue  about  these  structures  is  involved. 
Digital  examination  revels  the  exudate  in  the  broad  ligaments, 
more  commonly  on  the  left  side,  and  possibly  about  the  rectum, 
bladder,  or  above  Poupart's  ligament,  if  the  inflammation  spreads 
so  far.  If  suppuration  occurs,  the  septic  symptoms  continue  and 
the  mass  softens.  Pelvic  cellulitis  can  seldom  be  dift'erentiated 
from  pelvic  peritonitis,  indeed,  the  two  are  commonly  associated. 
Cellulitis,  however,  when  existing  alone,  is  less  painful,  more  often 
unilateral,  and  more  prone  to  suppurate,  and  it  bulges  into  the 
vagina,  displaces  the  uterus  laterally,  and  presents  no  exudate  in 
the  peritoneal  pouches  in  front  of  and  behind  the  uterus  (Fig.  544)- 

The  treatment  is  that  of  pelvic  peiitonitis.  If  suppuration 
occurs,  the  abscess  should  be  incised  either  through  the  vagina  or 
above  Poupart's  ligament,  according  to  its  situation.  In  doubtful 
cases  the  abdomen  may  be  opened  in  the  median  line,  the  relations 
of  the  mass  determined,  and  in  the  absence  of  disease  of  the  appen- 
dages the  abdomen  closed  and  the  abscess  opened  through  the 
vagina.  Organized  exudate  is  treated  by  hot  sitz  baths,  hot  vaginal 
douches,  pressure  by  boro-glycerid  tampons  in  the  vagina  and 
shot  bags  on  the  lower  abdomen,  and  by  the  internal  administration 
of  potassium  iodid  and  tonics. 

Pelvic  hematocele  is  an  effusion  of  blood  into  the  cavity  of  the 


GENITAL   ORGANS  973 

pelvic  peritoneum.  It  is  almost  always  due  to  a  rupluied  ectopic 
pregnancy  or  a  tubal  abortion,  but  may  be  caused  also  by  rupture 
of  an  ovarian  hematoma,  excessive  bleeding  following  rupture  of  a 
Graafian  follicle,  rupture  of  peritoneal  adhesions  from  traumatism, 
regurgitation  of  blood  in  atresia  of  the  genital  canal,  malignant 
tumors  of  the  pelvis,  and  by  operations  on,  or  injuries  of,  any  of  the 
abdominal  viscera.  The  ])lood  gravitates  into  the  pouch  of  Douglas, 
where,  after  a  time,  it  coagulates  and  becomes  encapsulated  by 
adhesions.  Finally  it  may  undergo  absorption,  organization,  or 
suppuration.  The  symptoms  are  sudden  sharp  pain,  followed  by 
evidences  of  internal  bleeding  if  there  be  much  Iofs  of  blood.  When 
the  blood  coagulates,  there  may  be  signs  of  pressure  on  any  of  the 
pelvic  organs.  At  first  there  is  only  an  indefinite  fulness  in  the 
posterior  fornix,  but  as  the  blood  clots,  this  becomes  firmer  and  may 
crepitate  on  pressure. 

Pelvis  hematoma  is  an  extraperitoneal  effusion  of  blood,  usually 
betw'cen  the  folds  of  the  broad  ligament.  It  is  generally  due  to  the 
rupture  of  an  ectopic  pregnancy,  but  may  be  caused  also  by  spon- 
taneous or  traumatic  rupture  of  any  of  the  pelvic  vessels,  especially 
varices  of  the  broad  ligament.  The  symptoms  are  similar  to  those 
of  hematocele,  though  fatal  hemorrhage  is  less  common  and  coagula- 
tion occurs  more  quickly.  The  hematoma  is  felt  to  the  side  of  and 
behind  the  cervix,  displacing  the  uterus  forward  and  to  one  side, 
and  may  be  detected  above  Poupart's  ligament  when  of  large  size. 
It  may  rupture  into  the  peritoneal  cavity,  vagina,  or  rectum,  and, 
Hke  hematocele,  it  may  undergo  absorption,  organization,  or  sup- 
puration. 

The  treatment  of  hematocele  and  hematoma,  the  result  of 
ectopic  pregnancy,  has  already  been  given.  When  due  to  other 
causes,  the  patient  should  be  confined  to  bed  and  ice  applied  to 
the  lower  abdomen.  If  the  mass  steadily  increases  in  size,  or  is 
accompanied  by  symptoms  of  internal  bleeding,  the  abdomen  should 
be  opened  and  the  hemorrhage  controlled.  If  suppuration  occurs, 
the  abscess  should  be  opened  through  the  vagina. 

Varicocele  of  the  broad  ligament  is  usually  the  result  of  dis- 
placements, tumors,  or  chronic  inflammation  of  the  pelvic  organs, 
or  other  conditions  producing  chronic  congestion,  such  as  con- 
stipation, sedentary  life,  and  chronic  diseases  of  the  heart,  lungs, 
or  liver.  As  in  the  male,  the  left  side  is  more  frequently  affected. 
The  symptoms  are  those  of  the  causative  lesion,  with  dull  aching 
pelvic  pain,  which  is  worse  on  standing  and  relieved  by  the  recumbent 
posture.     The  treatment  is  removal  of  the  cause  and  attention  to 


974  MANUAL   OF   SURGERY 

the  general  health.  When  the  abdomen  is  opened  for  other  reasons, 
the  veins,  as  well  as  any  calcified  thrombi  {phleholiths) ,  may  be 
excised. 

Neoplasms  of  the  pelvic  connective  tissue  require  no  special 
description.  When  intraligamentary  they  may  be  removed  in  the 
same  way  as  parovarian  cysts  or  intraligamentary  fibroids  of  the 
uterus. 


CHAPTER  XXXI 
EXTREMITIES 

Congenital  elevation  of  the  scapula  {SprengeVs  deformity)  is 
rare.  The  scapula  is  elevated,  and  its  lower  angle  rotated  toward 
the  spine.  It  may  be  associated  with  scoliosis,  and  asymmetry  of 
the  head.  The  suprascapular  muscles  are  shortened  and  sometimes 
ossified.  When  seen  early  in  life  the  contracted  muscles  should  be 
divided. 

Scapulum  alatum,  or  winged  scapula,  was  formerly  supposed  to 
be  due  to  slipping  of  the  lower  angle  of  the  bone  from  beneath  the 
fibers  of  the  latissimus  dorsi,  hence  the  term  dislocation  of  the  lower 
angle  of  the  scapula;  it  is  now  known  to  be  due  to  paralysis  of  the  ser- 
ratus  magnus  following  poliomyelitis,  or  neuritis,  rupture,  or  con- 
tusion of  the  long  thoracic  nerve.  The  treatment  is  electricity,  mas- 
sage, strychnin,  and  in  some  cases  a  brace.  Suture  of  the  divided 
nerve,  or  its  anastomosis  to  the  posterior  cord  of  the  brachial  plexus, 
may  be  considered  in  cases  depending  upon  section  of  the  nerve. 
Tubby  transplants  the  lower  portion  of  the  pectoraHs  major  to  the 
digitations  of  the  serratus  magnus,  after  spHtting  it  to  correspond 
to  these  serrations.  When  bilateral  the  scapulae  may  be  sutured 
together  (von  Eiselberg).  Duval  sutures  the  inner  border  of  the 
scapula  to  the  sixth  and  seventh  ribs. 

Subdeltoid  (subacromial)  bursitis  may  be  due  to  trauma,  gout, 
rheumatism,  syphilis,  tuberculosis.  Codman  describes  three  forms. 
In  the  acute  form  there  is  pain  on  voluntary,  but  not  on  passive,  ab- 
duction of  the  arm.  The  pain  is  referred  to  the  insertion  of  the 
deltoid,  and  sometimes  runs  up  into  the  neck,  or  down  the  arm, 
even  to  the  hand.  The  pain  is  worse  at  night,  and  the  patient  may 
be  unable  to  sleep  on  the  affected  side.  When  the  arm  is  voluntarily 
abducted  or  rotated  externally,  the  motion  is  at  first  free,  then  the 
scapula  is  locked  by  spasm  and  accompanies  the  humerus.  The 
tenderness  is  located  on  the  point  of  the  shoulder,  just  below  the 
acromion  and  outside  the  bicipital  groove,  and,  owing  to  the  bursa 
becoming  entirely  subacromial  when  the  arm  is  abducted,  may  disap- 
pear when  the  limb  assumes  this  position.  This  sign  is  almost  path- 
ognomonic. The  swelling  may  or  may  not  be  apparent.  With 
proper  treatment  recovery  occurs  in  a  few  weeks.     In  the  subacute 

975 


976  MANUAL    OF   SURGERY 

form  there  are  adhesions  within  the  bursa,  hence  a  mechanical  ob- 
stacle to  abduction  and  external  rotation,  and  persistence  of  the 
tender  point  when  the  arm  is  abducted.  These  symptoms  may  per- 
sist for  a  year  or  two.  In  the  chronic  form  the  bursa  is  irregularly 
thickened.  Motion  may  be  free,  but  at  some  point  in  abduction 
there  is  pain,  which  disappears  when  the  tuberosity  of  the  humerus 
passes  beneath  the  acromion,  only  to  recur  when  the  arm  is  lowered 
again.  In  some  of  the  chronic  cases  the  symptoms  are  intermittent, 
disappearing  and  reappearing  irregularly. 

The  diagnosis  from  inflammation  of  the  sheath  of  the  biceps 
tendon  is  made  by  accurately  localizing  the  seat  of  the  tenderness, 
and  by  noting  that  in  this  condition  abduction  is  painful  from  the 
start.  In  paralysis  of  the  deltoid  (circumflex  nerve)  the  deltoid 
is  atrophied  and  does  not  contract.  Acromio-calvicular  arthritis 
causes  thickening  of  the  joint,  over  which  the  tenderness  is  situated. 
A  deep  axillary  abscess  may  cause  fixation  of  the  shoulder,  but  should 
be  detected  by  careful  examination.  Fractures  about  the  shoulder 
and  tuberculosis  of  the  head  of  the  humerus  may  be  excluded  by 
the  X-ray. 

The  general  treatment  is  attention  to  any  existing  diathesis.  In 
the  acute  form  rest  may  be  obtained  by  keeping  the  arm  abducted 
on  a  table  or,  at  night,  on  a  pillow;  this  relaxes  the  deltoid  and  the 
short  rotators,  and  prevents  the  tender  point  at  the  base  of  the  bursa 
from  coming  in  contact  with  the  tip  of  the  acromion.  Local  ap- 
plications of  ichthyol,  iodin,  etc.,  may  be  of  some  use.  Passive 
motions  should  be  made  from  time  to  time  to  prevent  the  formation 
of  adhesions.  Subacute  cases  may  be  treated  by  massage,  passive 
and  active  motions,  baking,  rupture  of  the  adhesions  under  an  anes- 
thetic, incision  and  division  of  the  adhesions,  excision  of  the  sub- 
deltoid portion  of  the  bursa.  If  the  bursa  is  to  be  opened  or  excised, 
the  elbow  is  flexed  to  a  right  angle,  the  humerus  placed  at  the  side 
midway  between  internal  and  external  rotation,  and  a  vertical  incision, 
two  or  three  inches  in  length,  made  over  the  external  lip  of  the  bicipi- 
tal groove.  The  fibres  of  the  deltoid  are  separated,  the  bursa  opened, 
and,  after  strong  downward  traction  is  made  on  the  arm,  a  finger 
introduced  into  the  cavity  between  the  tuberosity  and  the  acromion. 
Adhesions  may  be  ruptured  or  cut,  exostoses  removed,  or  the  lower 
part  of  the  bursa  excised.  The  arm  is  dressed  in  abduction,  and 
passive  motion  begun  early, 

Volkmann's  contracture  {ischemic  myositis),  is  a  claw-like  con- 
traction of  the  interphalangeal  joints  of  the  fingers,  the  metacar- 
pophalangeal articulations  remaining  straight.     In  the  milder  forms 


EXTREMITIES 


977 


the  fingers  can  be  straightened  when  the  wrist  is  bent;  in  the  worst 
cases  the  wrist  also  is  strongly  tlexed  (Fig.  545).  The  forearm  is 
pronated  and  slightly  flexed.  The  condition  is  usually  due  to  the 
compression  of  a  splint  or  a  bandage,  applied  for  the  treatment  of  a 
fracture,  but  has  followed  also  a  simple  contusion  without  the  applica- 
tion of  a  bandage.  Other  rare  causes  are  the  Esmarch  band,  and 
embolism,  thrombosis,  or  ligation  of  the  brachial  artery.  The 
flexor  and  pronator  muscles  on  the  anterior  aspect  of  the  forearm  are 
shortened,  atrophied,  hard,  anemic  (grayish  in  color),  and  friable. 
In  rapid  or  old  cases  the  nerves  and  the  vessels  are  enveloped  in  a 
fibrous  mass,  and  even  the  bones  are  softened  and  atrophied.  The 
reason  for  these  changes  is  ischemia,  followed  by  infiltration  of  blood 
between  the  muscular  fibres,  and  later  by  degeneration  of  the  muscles. 
Neuritis,  which  some  hold  responsible  for  the  ischemic  myositis,  is, 
when  present,  always  secondary.     In  all  the  reported  cases  the  age 


Pig.  545- 


-Volkmann's  contracture,  from  the  pressure  of  a  splint;  treated  by  tendon 
lengthening. 


of  the  patient  was  between  three  and  fifteen  years  (Berger).  Pain 
and  edema  of  the  bandaged  forearm  generally,  but  not  invariably, 
precede  the  development  of  the  deformity.  The  contraction  may 
be  apparent  when  the  splint  is  removed,  or  it  may  not  appear  for 
weeks.  The  hardened  muscles  can  be  palpated,  splint  sores  are 
often  present,  and  if  there  is  neuritis,  the  symptoms  of  this  afi'ection 
are  in  evidence. 

The  diagnosis  is  rarely  difficult.  In  cicatricial  contraction  in- 
volving the  tendons  in  the  palm  the  fingers  cannot  be  extended  when 
the  wrist  is  flexed.  Hemiplegic  and  post-paralytic  contractures 
yield  under  general  anesthesia.  In  deformities  due  to  ankylosis  of 
the  fingers  or  wrist  the  joints  are  rigid. 

Prophylaxis,  after  a  fracture  of  the  forearm  or  elbow,  consists  in 
avoiding  tight  bandages,  indeed  if  there  is  much  swelling,  reduction 
of  the  fracture  and  dressing  may  be  postponed  for  a  day  or  two,  unless 


C2 


978  MANUAL    OF   SURGERY 

it  is  thought  that  the  displaced  fragment  is  contributing  to  the  edema. 
The  Jones  position  Hkewise  should  not  be  employed  immediately- 
after  the  accident.  If  the  cyanosis  and  edema  continue  when  the 
forearm  is  elevated  and  extended,  Murphy  advises  subcutaneous 
incision  of  the  fascia  on  the  antero-ulnar  side  of  the  forearm,  for  a 
distance  of  several  inches.  This,  he  states,  must  be  done  within  t,6 
hours  if  a  good  result  is  to  be  obtained. 

The  treatment  is  nonoperative  or  operative.  The  nonoperative 
treatment  consists  in  gradually  and  daily  stretching  the  contracted 
tissues,  manually  or  by  specially  constructed  splints.  Electricity, 
massage,  and  baking  in  the  hot  air  apparatus  are  useful  adjuncts. 
This  treatment  must  be  continued  for  months  or  years.  The  opera- 
tions that  have  been  employed  are  neurolysis,  elongation  of  the 
tendons,  and,  in  order  to  shorten  the  arm,  resection  of  a  portion  of 
the  radius  and  ulna.  The  last  is  sometimes  followed  by  pseudar- 
throsis,  hence  the  fragments  should  be  fastened  together  by  wire  or 
other  means.     Berger  advises,  in  order  to  avoid  fusion  of  the  callus 

from  the  two  bones,  resection  of  the 
radius  at  its  upper  part,  of  the  ulna 
at  its  lower  part;  a  further  advantage 
of  this  proceeding  is  the  small  calibre 
of  the  bones  at  these  points. 

Fig.  546. — Madelung's  deformity.  /-ti    1     1  1  ^  i  i  1 

CluD-nand  may  be  palmar,  dorsal, 
radial,  or  ulnar,  depending  on  the  direction  of  the  deviation.  In 
congenital  absence  of  the  radius  there  is  a  pronounced  radial  club- 
hand. The  mildest  cases  may  be  remedied  by  massage  and  passive 
motion;  in  others  tenotomy  will  be  required.  When  the  bones  are 
much  altered,  osteotomy  of  one  of  the  bones  of  the  forearm  or  re- 
moval of  one  or  more  of  the  carpal  bones,  according  to  the  type  of 
deformity,  may  be  needed. 

Madelung's  deformity  (Fig.  546)  is  progressive  forward  (rarely 
backard)  subluxation  of  the  radiocarpal  joint,  due  to  relaxation  of 
the  ligaments  or  to  disturbance  in  the  growth  of  the  radial  epiphysis. 
Eighty  per  cent,  of  the  cases  occur  in  girls  during  adolescence.  The 
lower  end  of  the  ulna  is  prominent,  the  radius  often  curved,  and  the 
hand  usually  adducted  but  occasionally  abducted.  Extension  and 
sometimes  flexion  of  the  wrist  are  impaired.  The  treatment  in  the 
early  stages  is  a  retentive  apparatus,  e.g.,  a  leather  cuff.  At  a 
later  period  tenotomy,  reduction  through  an  incision,  or  cuneiform 
osteotomy  of  the  radius  may  be  indicated. 

Polydactylism,  or  supernumerary  fingers  or  toes,  requires  ampu- 
tation of  the  accessory  digits  if  they  are  useless  or  troublesome. 


EXTREMITIES  979 

Macrodactylism,  or  congenital  hypertrophy  of  one  or  more  fingers 
or  toes,  also  may  require  amputation.  Ectrodactylism  is  the  ab- 
sence of  one  or  more  digits.  Syndactylism,  or  webbed  lingers,  is 
treated  by  incising  the  web  in  such  a  way  as  to  form  a  flap  which  is 
used  to  cover  the  raw  surface  between  the  roots  of  the  fingers,  or  by 
raising  two  flaps  of  skin  by  an  incision  along  the  middle  of  the  palmar 
surface  of  one  finger  and  another  along  the  middle  of  the  dorsal 
surface  of  the  other  finger,  the  flaps  being  wrapped  around  the  digits 
after  they  have  been  separated. 

Congenital  contraction  of  the  fingers  corresponds  to  congenital 
hammer-toe,  with  which  it  is  sometimes  associated.  The  little  finger 
is  the  one  usually  affected.  The  first  phalanx  is  hyperextended  and 
the  second  and  third  flexed,  thus  differing  from  Dupuytren's  con- 
traction, in  which  the  first  and  second  phalanges  are  flexed  and  the 
third  extended.  In  the  former  the  middle,  and  in  the  latter  the 
lateral  digital  processes  of  the  palmar  fascia  are  shortened.  The 
treatment  is  forcible  correction  and  the  application  of  a  splint,  or 
division  of  the  contracted  fascia. 

Snap-  or  trigger -finger  is  an  acquired  deformity  in  which  one  or 
possibly  two  fingers  can  be  extended  only  by  great  effort  or  by  using 
the  other  hand,  when  the  finger  flies  out  like  the  blade  of  a  penknife. 
Over  90  per  cent,  of  the  cases  are  caused  by  some  condition  that 
offers  a  limited  obstruction  to  the  play  to  the  tendon  in  its  sheath, 
e.g.,  contraction  of  the  sheath,  enlarged  sesamoid,  ganglion,  a  growth 
on  the  tendon,  or,  most  frequently,  a  localized  fibroid  thickening  of 
the  tendon,  as  the  result  of  repeated  contusions,  or  a  partial  tear,  of 
the  tendon,  the  lesion  usually  being  situated  over  the  metacarpo- 
phalangeal joint,  at  which  point  the  "tendon  callus"  can  often  be 
felt.  In  less  than  lo  per  cent,  of  the  cases  the  trouble  is  due  to  an 
alteration  in  the  relations  of  the  joint  surfaces  the  result  of  injury 
or  disease.  The  treatment  is  removal  of  the  obstruction.  In  the 
usual  variety  it  is  necessary  only  to  incise  the  theca  over  the  fusiform 
enlargement  of  the  tendon. 

Baseball  finger  is  the  result  of  a  blow  of  a  baseball  on  the  palmar 
surface  or,  more  frequently,  on  the  end  of  the  finger.  The  injuries 
may  be  divided  into  two  groups.  In  the  first,  one  of  the  interpha- 
langeal  joints  is  tender  and  swollen,  and  a  fusiform  enlargement 
persists  long  after  the  injury.  The  lesion  may  be  a  sprain  or  a  dis- 
location, but  in  many  instances  there  is  a  fissured  fracture  of  the  end 
of  one  of  the  phalanges,  hence  a  skiagram  should  always  be  taken. 
The  treatment  is  the  reduction  of  any  deformity  that  may  be  present, 
a  palmar  splint  for  three  weeks,  and  later  massage.     In  the  second 


98o 


MANUAL   OF   SURGERY 


group  (mallet  finger)  the  extensor  tendon  is  stretched  or  torn,  as 
described  in  the  next  paragraph. 

Mallet  finger  is  a  drooping  of  the  distal  phalanx  as  the  result  of 
rupture  or  overstretching  of  the  end  of  the  extensor  tendon,  such  as 
may  be  caused  by  sudden  and  violent  hyperflexion  of  the  end  of  the 
finger.  In  the  early  stages  it  is  treated  by  the  application  of  a 
splint.  If  the  deformity  persists,  the  tendon  may  be  sutured  to 
the  periosteum. 

Dupuytren's  contraction  (Fig.  547)  is  a  shortening  of  the  palmar 
fascia  the  result  of  a  chronic  cirrhotic  inflammation,  which  begins 
as  an  induration  in  the  palm,  and,  as  it  progresses,  gradually  puckers 
the  skin  and  causes  a  permanent  flexion  of  the  little  and  ring  fingers, 
and  less  frequently  of  the  remaining  fingers.  It  is  most  common  in 
middle  aged  men  and  may  be  bilateral.     Occasionally  it  follows  long 

continued  pressure,  such  as  is  necessi- 
tated by  the  use  of  certain  tools,  and 
a  gouty  or  rheumatic  history  is  often 
obtainable.  On  .seeing  his  first  case, 
the  student  feels  the  tense  bands  of 
fascia  and  almost  invariably  makes  a 
diagnosis  of  contracted  tendon,  a  con- 
dition which  may  readily  be  differen- 
tiated by  noting  that  the  finger  can  be 
extended  when  the  wrist  is  flexed. 
The  treatment  is  excision  of  the  con- 
tracted fascia,  either  through  longi- 
tudinal incisions,  or  after  dissecting  off 
the  skin  in  the  form  of  a  flap.  Removal 
of  the  puckered  skin  with  the  fascia,  the  raw  surface  being  sub- 
sequently covered  if  small,  with  a  Wolf  graft,  or,  if  large,  with  a 
pedunculated  flap  from  the  forearm  or  abdomen,  is  probably  a 
better  operation.  Subcutaneous  section  of  the  tense  bands  is  un- 
satisfactory. Injections  of  thiosinamin  (fibrolysin)  are  recom- 
mended by  some  therapeutists. 

Foreign  bodies  in  the  palm,  especially  needles,  are  often  difficult 
to  find,  because  they  may  lodge  in  a  ligament,  a  tendon,  or  because 
they  are  moved  before  operation  by  muscular  contractions  or  pre- 
liminary scrubbing,  or  during  operation  by  the  manipulations  of  the 
surgeon.  If  a  needle  is  in  a  tendon  it  can  be  seen  to  move  with  the 
fluoroscope  when  the  tendon  moves.  The  foreign  body  should  be 
locaUzed  accurately  with  the  X-ray,  and  removed  at  once,  before  it  has 
had  time  to  migrate.     If  it  is  not  found  quickly,  one  should  stop, 


Fig.   547. — Dupuytren's  contraction. 


EXTREMITIES  98 1 

and  have  another  X-ray  examination  made,  as  extensive  multilation 
may  do  more  harm  than  the  foreign  body.  In  hospital  work  the 
patient  may  be  transferred  to  the  X-ray  room,  and  the  foreign  body 
extracted  with  the  aid  of  the  fluoroscope. 

Felon,  whitlow,  or  pyogenic  infection  of  the  tissues  on  the  palmar 
aspect  of  tlic  rmgcr  occurs  in  four  forms. 

1 .  The  subcuticular,  or  blister-like,  is  a  collection  of  pus  under  the 
epidermis,  due  to  infection  of  a  sweat  gland  or  possibly  a  superficial 
lobule  of  fat,  the  pus  in  the  latter  instance  perforating  the  true  skin. 
The  raised  epidermis  should  be  removed  with  forceps  and  scissors, 
and  if  a  perforation  in  the  skin  is  found  communicating  with  a  deeper 
collection,  the  perforation  should  be  enlarged. 

2.  The  subcutaneous  form  is  a  cellulitis,  usually  located  over  the 
distal  phalanx,  and  preceded  by  a  contusion  or  a  wound.  There  are 
tense  swelling,  great  tenderness,  and  severe  throbbing  pain,  espe- 
cially when  the  hand  is  dependent.  Fluctuation  is  rarely  detected 
unless  the  abscess  is  about  to  break.  The  process  occasionally 
spreads  to  the  cellular  tissue  over  the  middle  phalanx,  and  thence  to 
the  tendon  sheath  (which  is  absent  over  the  distal  phalanx),  but  is 
more  likely,  owing  to  the  perpendicular  arrangement  of  the  trabe- 
cules of  the  pulp,  to  extend  to  the  bone.  Painless  and  destructive 
felons  may  occur  in  certain  nervous  maladies,  notably  syringomyelia. 
The  treatment  is  incision  along  the  side  of  the  pulp  of  the  finger  (Fig. 
548  A),  continued,  if  the  process  be  extensive,  around  the  end  and 
then  along  the  opposite  side,  thus  raising  the  soft  parts  from  the 
bone  in  the  form  of  a  flap  (Fig.  548  B).  A  median  scar  is  unsightly, 
and  is  subjected  to  pressure  whenever  the  finger  is  used;  further,  if 
made  over  the  middle  or  the  proximal  phalanx  a  median  incision 
may  open  the  tendon  sheath,  thus  inaugurating  a  disastrous  teno- 
synovitis. The  wound  is  kept  open  with  gauze  impregnated  with 
vaselin,  and  the  finger  dressed  with  hot  antiseptic  fomentations. 

3.  The  subperiosteal,  or  bone  felon,  may  be  primary,  but  is  often 
secondary  to  the  subcutaneous  variety,  or  to  paronychia,  the  base  of 
the  nail  being  in  intimate  relation  with  the  bone.  The  symptoms 
are  those  of  subcutaneous  felon,  with  possibly  a  greater  amount  of 
pain.  The  treatment  is  cleavage  of  the  end  of  the  finger,  as  des- 
cribed in  the  preceding  paragraph,  and  incision  of  the  periosteum. 
After  the  acute  symptoms  have  subsided  the  flap  may  be  allowed  to 
fall  back  against  the  bone.  Later  the  amount  of  bone  devitalized 
may  be  shown  by  the  X-ray.  If  only  a  thin  scale  is  necrotic,  it  will 
soon  separate  and  be  discharged.  If  a  large  portion  or  the  whole  of 
the  diaphysis  has  perished  one  may  wait  until  it  becomes  loose,  a 


982 


MANUAL   OF   SUEGERY 


matter  of  four  or  five  weeks,  and  then  remove  it;  or,  perhaps  better, 
in^that  it  shortens  convalescence,  proceed  with  the  sequestrotomy 
as  soon  as  the  sequestrum  is  well  dehned.  The  epiphysis,  into  which 
the  tendons  are  inserted,  is  seldom  implicated,  hence  great  care 
should  be  taken  not  to  injure  it.  Occasionally,  however,  the  entire 
distal  phalanx,  the  joint,  and  a  portion  of  the  second  phalanx  are 
destroyed.  In  these  cases  one  may  fill  the  defect,  after  healing  has 
occurred,  by  transplanting  a  portion  of  the  crest  of  the  tibia,  or  in 
order  to  secure  a  joint,  the  bones  of  a  toe. 


Fig.  548. — Incisions  for  cellulitis  of  the  hand.  A.  Lateral.  B.  curved.  CD.  Bila- 
teral. E.  Hypothenar  space.  F.G.  Midpalmar  space.  H.  Thenal  space.  I,  Dorsal 
incision  for  thenar  space. 


4.  The  synovial,  or  thecal  form,  is  a  suppurative  tenosynovitis. 
It  may  be  associated  with  the  variety  just  described  or  follow  a 
cellulitis,  in  which  event,  if  prompt  drainage  has  been  estabUshed, 
it  is  possible  for  the  infection  to  locaKze  itself  to  a  segment  of  the 
sheath.  In  most  instances,  however,  and  especially  in  those  due  to 
a  streptococcic  infection  following  a  puncture  w^ound  of  the  sheath 
e.g.,  from  a  pin,  the  entire  synovial  sac  of  the  affected  finger  is  in- 
vaded. It  may  be  recalled  that  the  synovial  sheath  of  the  thumb 
and  each  finger  extends  distally  to  the  base  of  the  terminal  phalanx. 
Proximally  the  sheath  of  the  index,  the  middle,  and  the  ring  finger 


EXTREMITIES 


983 


each  reaches  the  neck  of  the  corresponding  metacarpal  bone,  or, 
roughly  estimated,  the  level  of  the  great  transverse  flexion  crease 
of  the  palm.  The  sheath  of  the  thumb  communicates  with  the 
external  (j*adial)  palmar  sac,  which  envelops  the  flexor  longus  pollicis 
only.  The  sheath  of  the  little  finger  is  continuous  with  the  internal 
(ulnar)  palmar  sac,  which  widens  in  the  palm  and  envelops  also  the 
tendons  of  the  ring,  the  middle,  and  the  index  fingers,  the  first  to  a 
considerable  extent,  the  second  less,  the  last  only  a  little.  As  there 
are  two  layers  of  tendons  to  be  enveloped,  there  are  three  culs  de 
sac,  the  pre-,  the  inter-,  and  the  retrotendinous;  the  first  is  the  small- 
est, the  last  the  largest,  consequently  pus  accumulates  easiest 
under  both  layers  of  tendon.  The 
internal  and  the  external  palmar  sacs 
converge  in  the  carpal  canal,  being 
separated  by  cellular  tissue,  in  which 
lies  the  median  nerve;  in  this  situa- 
tion they  are  in  close  relationship 
with  the  carpal  articulations,  which 
are  not  infrequently  invaded  by  in- 
fection from  the  palm.  The  sacs 
both  extend  into  the  forearm,  the  in- 
ternal to  a  point  about  one  inch  and 
a  quarter,  the  external  to  a  point 
about  one  inch  and  a  half,  above  the 
annular  ligament  (Fig.  549).  There 
are,    however,    frequent    anomalies.         p^^  549.-Diagram  showing  the 

The  tendon  sheath  of  the  little  finger     usual     arrangement     of     the    tendon 

,1.11  1  ^     1   r  sheaths  of  the  hand  (shaded)  and  the 

or  the  thumb  may  be  separated  from     relations  of  the  palmar  arches  (in  red) 

the  corresponding  palmar  sac,  hence    *?  *^^  l^'l^^  °l  \^^  p^^""-    Note  also 

the  position  of  the  digital  arteries. 

infection  of  the  sheaths  of  these  digits 

is  not  invariably  followed  by  palmar  synovitis.  The  two  palmar 
sacs  often  communicate,  either  directly,  or  by  a  median  sac,  usually 
annexed  to  the  deep  flexor  tendon  of  the  index  finger;  and  the 
digital  sacs  of  the  first  three  lingers  may  communicate  with  the 
internal  palmar  sac,  so  that  it  is  possible  to  have  a  total  palmar 
synovitis  following  infection  of  the  thumb  or  any  of  the  fingers. 
Excluding  these  variations,  we  may,  for  the  purpose  of  description, 
take  suppurative  synovitis  of  the  first  three  fingers  as  the  type  of 
digital  thecal  infection,  reserving  that  of  the  thumb  and  the  Httle 
finger  for  discussion  with  palmar  abscess. 

The  symptoms  of  suppurative  thecitis  of  the  index,  the  middle,  or 
the  ring  finger  are,  w^hen  the  sheath  alone  is  infected,  only  shght 


984 


MANUAL   OF    SURGERY 


redness  of  the  skin;  moderate  swelling,  most  marked  on  the  dorsum 
of  the  finger;  great  pain  on  moving  the  finger,  which  is  held  in  a 
flexed  position;  and  acute  deep  tenderness  sharply  localized  to  the 
sheath,  perhaps  most  intense  over  the  upper  end  and  bejieath  the 
digitopalmar  pad.  This  line  of  tenderness  can  be  mapped  out  by 
making  pressure  with  a  probe.  CelluUtis  may,  of  course,  precede  or 
follow  thecitis.  The  general  symptoms  are,  as  a  rule,  more  severe 
than  those  of  other  forms  of  infection. 


Pig.  550. — Incisions  for  synovitis  of  the  hand.  Lateral  for  little  finger  (A. A.),  ring 
finger  (B.B.),  index  finger  (D.D.),  and  thumb  (K).  Median  for  upper  end  of  distal 
sheath  (P.G.).  Bilateral  (C.C.C.).  Internal  palmar  sac  (E).  Upper  end  of  internal 
sac  (H),  of  external  sac  (I).     External  sac  (J). 

The  treatment  should  be  prompt,  in  order  to  save  the  tendon,  and 
to  prevent  rupture  of  the  sheath  and  diffusion  of  the  pus  into  the 
cellular  tissue  of  the  palm.  In  view  of  the  difficulty  sometimes 
experienced  in  differentiating  cellulitis  over  the  theca  from  thecitis 
with  cellulitis,  the  operation  should  be  of  an  exploratory  nature,  to 
permit  which  the  patient  should  be  anesthetized  and  the  part 
lendered  bloodless.  An  incision  is  then  made  alongside  of  the 
tendon  between  the  flexion  creases  of  the  finger,  in  the  region  of  the 
primary  infection  (Fig.  550  D).  If  the  sheath  is  reddened,  edema- 
tous, distended,  it  contains  pus;  if  there  is  any  doubt  as  to  the  con- 


EXTREMITIES  985 

tents  of  the  sheath  it  may  be  explored  with  a  hypodermic  needle. 
If  infected  the  sheath  is  opened.  A  similar  incision  must  then  be 
made  over  the  other  phalanx  (the  distal  phalanx  is  not  concerned, 
unless  the  seat  of  the  primary  infection),  and  a  third  incision,  in  the 
axis  of  the  hnger,  through  the  digitopalmar  pad,  as  far  as  the  great 
transverse  crease  of  the  palm  (Fig.  550G).  Bilateral  incisions,  as 
shown  in  (Fig.  550C)  may  be  employed  if  freer  drainage  is  thought 
desirable.  The  incisions  should  never  cross  the  joints,  otherwise, 
particularly  with  a  long  median  incision,  the  tendon  is  dislocated 
from  its  sheath,  and  assumes,  in  its  relation  to  the  flexed  linger,  the 
position  of  the  string  to  a  bow.  Instruments  must  not  be  thrust 
beneath  the  tendon,  foi  fear  of  injuring  the  mesotendon  (vinculum), 
through  which  the  blood  vessels  run.  The  wounds  are  drained  with 
vasehnized  gauze,  which  should  extend  to,  but  not  into,  the  sheath,  a 
warm,  moist,  antiseptic  dressing  applied,  and  the  hand  put  on  a 
spUnt.  ISIany  surgeons  advise  Bier's  treatment,  but  we  believe 
prolonged  daily  soaking  in  hot  salt  solution  to  be  quite  as  efhcient  and 
without  the  disadvantages  of  passive  hyperemia.  If  incision  has 
been  delayed  for  several  days  the  tendon  sloughs  and,  after  three  or 
four  weeks,  is  discharged. 

Palmar  abscess  superficial  to  the  palmar  fascia  requires  no  special 
description.  Deep  palmar  abscess  follows  the  superficial  variety, 
a  wound  of  the  palm,  or  an  infected  finger,  the  lesion  being  a  sup- 
purative synovitis  or  celluhtis,  or  both.  The  general  symptoms  of 
sepsis  are  marked  in  both  varieties;  the  local  signs  and  the  treat- 
ment differ. 

Palmar  synovitis  may  be  divided  into  that  of  the  internal  and  that 
of  the  external  sac,  although  the  two  forms  are  often  combined. 

Suppuration  of  the  internal  {ulnar)  sac  following  a  thecitis  of  the 
Httle  finger  gives  the  signs  of  digital  thecitis  mentioned  above,  with 
swelling  and  tenderness  along  the  ulnar  side  of  the  palm,  and  above 
the  annular  ligament  to  the  ulnar  side  of  the  palmaris  longus.  The 
dorsum  of  the  hand  is  little  affected.  The  treatment  is  incision  of  the 
digital  theca  over  the  middle  and  the  proximal  phalanx,  as  already 
described  (or  at  the  point  of  infection  in  the  palm,  if  the  trouble 
started  in  the  palm),  when  it  will  be  found  that  pus  can  be  forced 
through  the  upper  wound  by  pressure  on  the  inner  side  of  the  palm. 
The  palmar  sac  is  now  opened  by  an  incision  (Fig.  550E)  running 
from  the  middle  of  the  digitopalmar  pad  of  the  little  finger,  up 
towards  the  radial  styloid,  to  a  line  crossing  the  palm  at  the  level 
of  the  web  of  the  thumb,  which  line  overlies  the  superficial  palmar 
arch.     Pressure  over  the  sac  above  the  annular  ligament  will  cause 


986  MANUAL    OF    SURGERY 

pus  to  flow  through  the  wound,  hence  another  incision  must  be 
made.  The  line  of  this  incision  is  parallel  and  just  external  to  that 
for  the  ulnar  artery;  it  commences  close  to  the  crease  of  the  wrist  and 
extends  upwards  for  about  one  and  a  half  inches  (Fig.  550H).  The 
flexor  carpi  ulnaris  and  ulnar  vessels  are  drawn  inwards,  the  other 
flexors  outwards,  and  the  sac  found  deeply  under  the  latter. 

Suppuration  of  the  external  {radial)  sac  due  to  a  thecitis  of  the 
thumb  also  gives  the  signs  of  digital  thecitis,  but  with  swelling  and 
tenderness  along  the  inner  side  of  the  thenar  muscles,  and  above  the 
annular  ligament  to  the  radial  side  of  the  palmaris  longus.  The 
treatment  proceeds  as  in  suppuration  of  the  internal  sac.  A  lateral 
incision  is  made  over  the  proximal  phalanx  of  the  thumb.  The 
second  incision  runs  from  the  base  of  the  thumb,  on  a  line  to  the 
ulnar  styloid,  for  about  one  inch  (Fig.  550J) .  The  short  flexor  of  the 
thumb  is  cut,  and  the  sac  identified  b}^  moving  the  thumb.  In  the 
upper  part  of  the  wound  the  thenar  branches  of  the  median  nerve 
must  be  avoided.  The  third  incision  is  above  the  annular  ligament 
parallel  to  and  just  within  the  line  of  the  radial  vessels,  which  must 
be  drawn  aside.  The  incision  runs  from  the  crease  of  the  wrist 
upwards  for  one  and  one  half  inches.  A  few  operators,  in  severe 
cases,  advise  severing  the  annular  ligament  over  the  radial  or  ulnar 
bursa,  or  over  both  bursae,  according  to  the  location  and  the  extent 
of  the  infection,  thus  making  the  palmar  and  the  forearm  incisions 
continuous. 

Palmar  cellulitis  causes  great  swelling  of  the  dorsum  of  the  hand, 
and,  owing  to  the  resistance  of  the  palmar  fascia,  only  slight  tume- 
faction of  the  palm.  The  point  of  greatest  tenderness,  however,  is 
in  the  palm,  and  it  is  by  this,  and  not  the  situation  of  the  maximum 
edema,  that  one  should  be  guided.  The  motion  of  the  fingers  is  not 
restricted,  because  the  synovial  sheaths  are  not  involved.  The 
subfacial  cellular  tissue  of  the  palm  surrounds  the  tendon  sheaths, 
and  extends  through  the  interdigital  spaces  to  the  digitopalmar  pads 
and  to  the  dorsum  of  the  hand,  and  through  the  carpal  canal,  be- 
tween the  synovial  sacs,  to  the  forearm.  According  to  Kanavel, 
pus  is  likely  to  accumulate  in  one  of  the  following  spaces.  The 
hypothenar  space  lies  beneath  the  hypothenar  muscles.  The  thenar 
space  occupies  the  area  of  the  thenar  eminence,  as  far  as  the  flexion 
and  adduction  crease  of  the  thumb,  but  does  not  extend  to  the  ulnar 
side  of  the  middle  metacarpal.  It  lies  deep  in  the  palm  just  above 
the  adductor  transversus.  The  middle  palmar  space  is  limited  by  the 
middle  metacarpal  on  the  radial  side,  is  overlapped  by  the  ulnar  bursa 
on  the  ulnar  side,  and  is  separated  from  the  thenar  space  by  a 


EXTREMITIES  987 

partition  which  is  firm  everywhere  except  at  the  proximal  end. 
Below  it  has  three  diverticula,  which  extend  along  the  lumbrical 
muscles.  Abscess  of  the  hypothenar  space  is  relatively  infrequent, 
and  is  opened  by  an  incision  parallel  and  internal  to  the  fifth  meta- 
carpal bone  (Fig.  548E).  The  thenar  space  is  often  invaded  by 
infection  from  the  thumb  or  the  index  finger,  occcasionally  from  the 
middle  finger.  This  space  may  be  opened  by  a  dorsal  incision  parallel 
to  the  metacarpal  bone  of  the  index  finger,  and  to  the  radial  side  of 
the  bellies  of  the  interossei  muscles  of  the  finger  (Fig.  548I).  Blunt 
forceps  are  pushed  across  the  palmar  surface  of  the  metacarpal  bone 
of  the  index  finger  into  the  space.  This  incision  does  not  scar  the 
palm  or  endanger  the  palmar  arch.  Intertendinous  palmar  incisions 
may  be  indicated  when  the  original  infection  enters  through  the 
palm.  Picque  incises  between  the  tendons  of  the  index  and  the 
middle  fingers  and  ties  the  superficial  palmar  arch  (Fig.  548H).  The 
mid-palmar  space  may  suppurate  as  the  result  of  infection  of  the 
middle,  the  ring  or  the  little  finger.  It  is  opened  by  an  incision 
starting  between  the  digitopalmar  pads  of  the  ring  and  the  little 
fingers,  and  extending  upward  toward  the  heel  of  the  hand  as  far  as 
the  superficial  arch  (Fig.  548F).  The  flexor  tendons  and  ulnar  bursa 
are  drawn  outward,  the  hypothenar  muscles  inward,  and  the  cellular 
space  beneath  the  tendons  drained.  It  may  be  drained  likewise 
through  the  lumbrical  space  between  the  middle  and  ring  finger,  by 
an  incision  betw'een  the  digitopalmar  pads  of  these  fingers.  If  the 
thenar  space  also  is  involved  a  drain  may  be  passed  beneath  the 
flexor  tendons  and  out  through  the  incision  which  has  been  made  into 
the  thenar  space.  Occasionally,  e.g.,  after  a  compound  fracture 
of  the  metacarpus,  the  dorsal  subaponeurotic  space  is  involved,  and 
it  becomes  necessary  to  push  a  pair  of  forceps  betw^een  the  bones 
and  between  the  extensor  tendons  to  the  skin,  which  is  opened^  and 
through-and-through  drainage  established. 

If  pain  and  fever  persist  after  free  drainage  of  palmar  infections 
it  may  be  due  to  septicemia,  lymphangitis,  or  lymphadenitis,  which 
are  treated  as  described  under  these  headings,  or  to  septic  arthritis 
of  the  carpal  joints  or  cellulitis  of  the  forearm.  Septic  arthritis  of 
the  wrist  demands  drainage  and  frequently  resection.  Cellulitis 
of  the  forearm  may  be  superficial,  but  is  often  deep,  the  infection 
coming  through  the  carpal  canal.  In  the  latter  instance  incisions 
are  made  close  to  the  volar  border  of  the  radius  and  the  ulna,  in  the 
lower  third  of  the  forearm,  the  tendons,  the  vessels,  and  the  nerves 
lifted  forward,  and  through-and-through  drainage  established. 
Similar  incisions  may  be  needed  also  in  the  upper  third  of  the  forearm. 


988  MANUAL   OF   SURGERY 

In  all  forms  of  palmar  abscess  the  drainage  material  should  be 
vaselinized  gauze,  rather  than  rubber  tubes,  which  may  induce 
necrosis.  Rubber  tissue  is  employed  by  some  surgeons,  but  is  more 
apt  to  slip  into  the  cavity  than  gauze.  Dry  gauze  acts  as  a  plug, 
and  causes  pain  and  bleeding  at  each  removal.  The  hand  should  be 
covered  with  a  warm,  moist,  antiseptic  dressing  and  be  put  on  a 
splint.  The  dressing  should  be  changed  at  least  once  a  day,  and  the 
hand  submerged  for  thirty  minutes  or  longer  in  a  warm  salt  solution 
bath.  After  the  acute  symptoms  subside  the  fingers  should  be 
moved  at  each  dressing,  in  order  to  prevent  adhesions  about  the 
tendons.  If  a  tendon  sloughs,  attempts  may  be  made,  after  the 
wounds  have  healed,  to  repair  the  loss  by  transplanting  a  segment 
of  the  palmaris  longus  tendon,  or  a  twisted  strip  of  the  fascia  lata. 

Jumping,  springing,  or  snapping  hip  {hanche  a  ressort,  schnap- 
pendeHufte)  is  characterized  by  a  sudden  jump  at  the  level  of  the  great 
trochanter,  on  flexion,  and  sometimes  on  extension,  of  the  thigh, 
which  jump  is  accompanied  by  a  noise,  expressed  onomatopoetically 
as  "cloc."  This  condition  has  been  ascribed  to  voluntary  subluxa- 
tion of  the  hip,  inflammation  or  absence  of  the  bursa,  osteoma,  vol- 
untary or  spasmodic  contraction  of  the  gluteus  maximus  or  tensor 
vaginae  femoris,  and  to  relaxation  of  the  ligaments  or  muscles.  It 
seems  probable,  however,  that  in  all  cases,  even  in  those  compli- 
cated by  subluxation,  which  is  not  common,  the  jump  and  snap  are 
due  to  slipping  of  the  anterior  border  of  the  gluteus  maximus  over 
•  the  trochanter,  for  at  the  time  of  the  snap  a  cord-like  structure  can 
be  seen  and  felt  to  glide  over  the  trochanter,  forwards  during  flexion 
backwards  during  extension,  and  the  snap  may  be  prevented  by 
fixing  the  cord  with  the  hand.  Clinically  there  are  two  varieties, 
the  congenital  and  the  acquired.  The  congenital  form,  which  is 
often  bilateral,  is  not  associated  with  pain  or  limping,  and,  according 
to  HeuUy,  is  due  to  a  low  insertion  of  the  gluteus  maximus  on  the 
femur.  The  acquired  form  usually  follows  an  injury  to  the  hip, 
and  is  the  result  of  tearing  of  the  upper  part  of  the  attachment  of 
the  gluteus  maximus  from  the  linea  aspera,  thus  allowing  the  anterior 
border  of  the  muscle,  with  its  attached  fascia,  to  slip  suddenly 
over  the  trochanter.  In  these  cases  there  may  be  pain  and  lameness, 
and,  to  avoid  the  "cloc,"  the  patient  may  keep  the  hip  extended, 
or  walk  bent  over  towards  the  well  side,  thus  causing  secondary 
scoliosis,  adduction  of  the  affected  limb,  elevation  of  the  anterior 
superior  spine  on  the  same  side,  and  apparent  projection  of  the 
trochanter.  Treatment  is  needed  only  when  the  trouble  seriously 
handicaps  the  patient.     The  anterior  edge  of  the  gluteus  maximus 


EXTREMITIES 


989 


may  be  sutured  to  the  periosteum  of  the  trochanter  (Bayer)  and,  in 
addition,  to  the  femoral  aponeurosis  and  vastus  externus  (Heully). 
Coxa  vara  is  a  downward  bending  of  the  neck  of  the  femur,  which 
may  form  and  angle  of  90°  or  even  less  with  the  shaft  of  the  bone. 
It  may  afifect  one  or  both  sides  and  is  frequent  in  young  males,  al- 
though it  may  occur  in  either  sex  and  at  any  period  of  life;  indeed  it 
is  physiological  in  old  age  and  may  be  congenital.  Diseases  which 
soften  the  osseous  tissue,  such  as  rickets,  osteomalacia,  ostitis  de- 
formans, and  chronic  inflammatory  afifections  of  bone,  as  well  as 
fracture  of  the  neck  of  the  femur,  may  result  in  coxa  vara.  The 
symptoms  are  pain  and  lameness.  The  limb  is  shortened,  the  tro- 
chanter above  Nelaton's  line,  and  abduction  limited.  The  foot  may 
be  everted  and  internal  rotation  restricted,  if  the  neck  is  twisted 
backwards,  and  less  commonly  in- 
verted with  the  restriction  of  ex- 
ternal rotation,  if  the  neck  is  twisted 
forward.  Careful  examination,  with 
a  radiogram,  will  usually  permit 
easy  differentiation  from  coxalgia  or 
congenital  dislocation.  The  treat- 
ment in  the  developing  stages  is  rest 
in  bed  with  extension,  or  the  use  of 
some  form  of  hip  splint,  for  a  number 

of   months,    in    order    to    prevent        Fig.  551-— i-  Normal  femur.     2    Coxa 

vara-cuneiform    osteotomy.     3.    Abduc- 
further   deformity,    the  nutrition  of    tion   of   Umb   fixes  the   upper   fragment 

the  limb  being  maintained  by  mas^  ^^^''^^^  ""^  °^  acetabulum  and  closes 
sage  and  electricity.     Persistent  de 
formity  when  disabling  may  be  cor- 
rected by  osteotomy,  either  linear  or  cuneiform  (Fig.  551). 

Coxa  valga  is  an  increase  in  the  angle  between  the  neck  and  shaft 
of  the  femur.  As  in  coxa  vara  the  neck  may  be  twisted  forwards 
or  backwards.  The  limb  is  lengthened,  the  trochanter  below  Nela- 
ton's line,  and  adduction  restricted.  It  has  been  found  associated 
with  diseases  like  those  mentioned  under  coxa  vara.  Osteotomy 
and  correction  of  the  deformity  may  possibly  be  indicated  in  some 
cases. 

Genu  valgum,  or  knock -knee,  is  an  abnormal  outward  deflection 
of  the  leg,  the  feet  being  separated  when  the  knees  are  together  in 
the  extended  position.  One  or  both  limbs  may  be  affected.  Accord- 
ing to  the  cause,  the  cases  may  be  grouped  in  three  classes: 

I.  Genu  valgum  rhachiticum  appears  soon  after  the  child  begins 
to  walk,  the  normal  angle  between  the  thigh  and  the  leg  being  ex- 


opening  in  bone.  4.  Replacement  of  limb 
after  union  if  complete  elevates  the  neck 
to  its  former  position.      (Whitman.) 


990  MANUAL   OF    SURGERY 

aggerated  as  the  result  of  lengthening  of  the  internal  condyle,  or 
bending  of  the  femur  above,  or  the  tibia  below,  the  knee.  The  in- 
ternal lateral  ligament  is  stretched,  and  the  joint  is  often  abnormally- 
movable  in  all  directions  {loose  knees).  2.  Genu  valgum  staticum 
is  most  common  during  adolescence  in  those  of  poor  physique, 
or  in  those  who  are  compelled  to  stand  much  or  to  carry  heavy 
weights.  It  is  supposed  by  some  to  be  due  to  a  latent  form  of  rickets. 
Owing  to  the  normal  obliquity  of  the  femur,  most  of  the  weight  of 
the  body  is  transmitted  to  the  tibia  through  the  external  condyle 
of  the  femur,  and  knock-knee  is  prevented  by  the  action  of  the  mus- 
cles on  the  inner  side  of  the  limb.  In  the  weak  or  overworked  these 
muscles  tire  and  the  individual  assumes  an  attitude  of  rest  with  the 
feet  separated  and  the  knees  extended,  thus  relaxing  the  muscles, 
stretching  the  internal  lateral  ligament,  and  ultimately  causing  atro- 
phy of  the  external  condyle  and  hypertrophy  of  the  internal  condyle. 
The  patella  passes  externally,  the  tissues  on  the  outside  of  the  limb 
are  contracted,  and  the  tibia  is  usually  rotated  outwards.  The  pa- 
tient has  a  rolling  gait,  and  scoliosis  may  follow  in  unilateral  cases. 
As  the  enlargement  of  the  internal  condyle  is  chiefly  in  the  vertical 
and  transverse  directions,  the  deformity  disappears  when  the  knee 
is  flexed  to  a  right  angle,  unless  the  tibia  is  curved.  3.  Other  causes 
of  knock-knee  are  infantile  or  other  forms  of  paralysis,  fracture  or 
dislocation  of  the  knee,  and  destructive  inflammatory  affections 
of  the  joint  or  neighboring  bones.  Flat-foot  may  be  either  the  cause 
or  the  result  of  knock-knee. 

The  treatment  during  the  early  stages  consists  in  keeping  the 
patient  off  the  feet  and  employing  massage  and  daily  corrective 
manipulations,  the  knee  being  pressed  outward  and  the  tibia  inward. 
Constitutional  measures  for  rickets,  or  in  static  cases  for  the  feeble 
general  health,  should  be  employed.  At  a  later  period  braces  con- 
sisting of  an  outside  steel  rod  running  from  the  trochanter  to  the 
foot  ,and  supplied  with  straps  for  pulling  the  knee  outward,  are  indi- 
cated. When  the  bones  have  become  thoroughly  ossified  (at  the  age 
of  three  or  four  in  children),  cure  can  be  obtained  only  by  operative 
treatment.  Macewen's  osteotomy  is  the  usual  operation.  The  outer 
side  of  the  knee  is  placed  on  a  sand  bag,  and  a  small  longitudinal 
incision  made  on  the  inner  side  just  above  the  adductor  tubercle. 
Through  this  an  osteotome,  which  differs  from  a  chisel  in  being 
beveled  on  both  sides,  is  passed  down  to  the  bone,  turned  trans- 
versely, and  driven  three-fourths  of  the  way  through  the  bone.  It  is 
then  withdrawn,  the  remaining  portion  of  the  bone  broken,  the  wound 
sutured,  and  the  limb  put  up  in  plaster  in  a  corrected  position 


EXTREMITIES  99 1 

Rarely,  and  only  in  the  worst  cases,  is  it  necessary  to  remove  a  wedge 
of  bone  [cuneiform  osteotomy).  The  cast  is  removed  in  six  weeks 
and  the  patient  allowed  to  walk  at  the  end  of  two  months. 

Genu  varum,  or  bow -leg,  is  the  reverse  of  genu  valgum,  the  ex- 
tended knees  being  separated  when  the  feet  are  together.  It  is 
almost  always  due  to  rickets,  which  permits  the  tibise  to  bend  outward. 
Occasionally  the  deformity  is  produced  by  a  bending  of  the  femur 
or  an  enlargement  of  the  external  condyle.  Anterior  bow-leg  is  a 
forward  curve  cf  the  tibia,  usually  near  one  extremity  of  the  bone,  and 
generally  associated  with  some  lateral  deviation,  thus  differing  from 
the  sabre  blade  deformity  of  syphilis,  which  is  due  to  a  hyperplasia 
rather  than  a  bending  of  the  bone,  and  which  is  generally  regular 
and  without  a  twist.  Posterior  bow-leg  or  genu  recurvatum  is  the 
reverse  of  anterior  bow-leg.  The  treatment  is  correction  by  daily 
manipulations  or  the  use  of  braces,  up  to  the  age  of  three  or  four 
after  which  operative  treatment  offers  the  only  hope  of  success. 
Osteotomy  of  the  tibia  is  performed  at  the  point  of  greatest  curva- 
ture, in  the  same  manner  as  osteotomy  for  knock-knee,  the  fibula 
being  broken  manually.  The  cast  is  removed  in  four  weeks  and 
the  patient  allowed  to  walk  at  the  end  of  six  weeks  Osteoclasis,  or 
fracture  of  the  bone  by  a  special  apparatus,  the  osteoclast,  is  pre- 
ferred by  some  surgeons,  but  should  not  be  employed  when  the  curve 
is  near  a  joint  or  the  bone  very  strong. 

Rupture  of  the  plantaris  [tennis  leg)  may  occur  during  climbing 
jumping,  boxing,  tennis,  and  similar  exercises.  There  is  a  sharp 
pain  in  the  calf  like  the  sting  of  a  whip  {coup  de  fouet) ,  tenderness, 
swelling,  and,  after  a  day  or  two,  ecchymosis  along  the  posterior 
surface  of  the  leg;  identical  symptoms  are  produced  by  the  rupture 
of  a  deep  varix.  The  treatment  is  rest  of  the  leg  for  one  week,  ich- 
thyol,  and  a  firm  bandage.  Later  the  patient  may  walk,  but  should 
not  rise  on  the  toes  for  several  weeks. 

Talipes,  or  club-foot,  is  an  abnormal  and  permanent  deviation  of 
the  foot  in  the  direction  of  extension  (T.  equinus),  flexion  (T.  cal- 
caneus), adduction  (T.  varus),  or  abduction  (T.  valgus).  Combina- 
tions of  these  forms  occur,  such  as  T.  equino-valgus  or  varus,  and 
T.  calcaneo-valgus  or  varus. 

The  causes  are  congenital  and  acquired.  Congenital  club-foot 
may  be  due  to  abnormal  intrauterine  pressure,  to  defective  develop- 
ment of  the  bones  of  the  leg,  or  to  some  nerve  lesion,  e.g.,  when 
associated  with  spina  bifida.  It  is  often  bilateral,  sometimes  heredi- 
tary, and  usually  not  associated  with  the  wasting,  trophic  changes, 
and  impaired  electrical  reactions  observed  in  the  acquired  paralytic 


992  MANUAL   OF   SURGERY 

form.  Acquired  club-foot  may  arise  from  paralysis  from  any  cause 
but  particularly  that  form  following  anterior  poliomyelitis  (paralytic 
talipes) ,  from  spasmodic  affections  of  certain  groups  of  muscles  {spas- 
tic talipes),  cicatrical  contraction  of  the  soft  parts  following  injury 
or  disease,  rupture  of  tendons  or  muscles,  fractures  about  the  ankle, 
burns,  (traumatic  talipes) ,  and  epiphysitis.  Shortening  of  the  lower 
extremity  from  any  cause  is  often  followed  by  a  compensatory  talipes 
equinus,  while  prolonged  fixation  of  the  foot  in  any  position  may  lead 
to  deformity,  e.g.,  the  pointed  foot  following  prolonged  confinement 
to  bed  (talipes  decubitus) ,  or  the  improper  application  of  a  plaster 
cast.  The  anatomical  changes  vary  with  the  degree  and  type  of 
deformity.  The  midtarsal  joint  (os  calcis  with  cuboid,  and  astra- 
galus with  scaphoid)  is  the  one  most  frequently  and  most  extensively 
involved,  the  ankle  joint  being  most  affected  in  equinus  and  calcan- 
eus. In  severe  cases  the  bones  are  altered  in  shape,  the  tendons  run 
in  abnormal  directions,  the  weak  or  paralyzed  muscles  are  stretched 
or  atrophied  while  their  opponents  are  shortened,  the  ligaments  and 
fasciae  are  contracted  or  stretched,  and  the  skin  is  thickened,  per- 
haps with  corns  or  ulcers,  at  the  points  where  the  foot  rests  on  the 
ground.     Abnormal  bursae  also  may  form. 

The  treatment  is  (i)  mechanical,  i.e.,  manipulation,  plaster-of- 
Paris  bandages,  and  braces,  or  (2)  operative,  i.e.,  tenotomy,  tendon 
lengthening,  shortening,  or  transplantation,  syndesmotomy  or  fas- 
ciotomy,  myotomy  (rare),  brisement  force,  open  incision,  tarsotomy 
or  tarsectomy,  bone  transplantation,  nerve  transplantation,  arthro- 
desis and  in  the  worst  cases  amputation.  Manipulation  consists 
in  holding  the  foot  in  a  corrected  position  for  a  few  minutes  several 
times  daily;  it  is  indicated  in  recent  cases  of  mild  degree.  An  ex- 
tension of  this  method  is  the  application  of  plaster-oj Paris  bandages, 
after  the  deformity  has  been  corrected  as  much  as  possible.  When 
the  cast  becomes  loose,  further  correction  is  made  and  a  second 
bandage  applied,  and  so  on,  until  the  foot  returns  to  its  normal 
position.  Braces  and  shoes  are  employed,  not  so  much  for  correc- 
tion, as  for  the  maintenance  of  the  normal  position  after  the  deform- 
ity has  been  reduced  by  other  means. 

Operative  treatment  of  some  form  is  required  in  all  but  the  mild- 
est cases,  and  varies  with  the  t3^e  of  deformity.  Talipes  equine - 
varus  (Fig.  552)  is  the  commonest  form  of  club-foo't,  and  when  bi- 
lateral is  called  reel-feet,  owing  to  the  fact  that  the  feet  are  lifted  one 
over  the  other  when  the  patient  walks.  The  heel  is  drawn  up  and 
the  foot" twisted  and  folded  on  itself,  so  that  the  toes  point  inwards 
and  the  patient  walks  on  the  outer  border  or  dorsum.     When  the 


EXTREMITIES 


993 


Fig.   552. — Talipes  equino-varus. 


measures  mentioned  above  have  failed  or  are  inadvisable,  the  varus 
may  be  corrected  after  tenotomy  of  the  tibialis  anticus,  tibialis  pos- 
ticus, and  plantar  fascia  {jasciolomy) ,  and  the  cquinus  may  then  be 
overcome  by  section  or  lengthening  of  the  tendo  Achillis.  Division 
of  the  contracted  ligaments  on 
the  inner  side  of  the  foot  {syndes- 
motomy)  also  may  be  needed. 
In  any  operation  for  club-foot 
the  deformity  should  be  over- 
corrected  and  the  foot  and  leg 
put  up  in  plaster,  which  should 
not  be  disturbed  for  two  or  three 
months.  After  the  plaster  has 
been  removed,  braces  will  be 
needed  until  there  is  no  longer 
any  tendency  towards  recur- 
rence, usually  a  matter  of  some 
years.  In  paralytic  cases  a  permanent  brace  may  be  required. 
Brisement  force  is  immediate  forcible  correction  by  the  hands  or  by 
instruments  (Fig.  553).  Open  incision,  or  Phelps'  operation,  con- 
sists in  dividing  all  the  tissues  on  the  inner  side  of  the 
foot  down  to  the  bone,  by  an  incision  extending  from 
the  internal  malleolus  to  one-fourth  of  the  distance 
across  the  sole  of  the  foot.  The  wound  is  packed 
with  gauze,  and  the  foot  put  up  in  plaster  in  an  over- 
corrected  position.  Jones  raises  a  triangular  flap, 
thus  lessening  the  gap  after  correction  of  the  defor- 
mity. When  the  bones  are  so  altered  in  shape  as  to 
prevent  reduction,  the  osseous  tissue  itself  must  be 
attacked.  According  to  the  situation  of  the  obstruc- 
tion, osteotomy  may  be  performed  upon  the  neck  of 
the  astragalus  through  an  incision  below  the  internal 
malleolus,  upon  the  head  of  the  os  calcis  through  an 
incision  below  the  external  malleolus,  or  upon  the 
scaphoid  through  an  incision  in  the  sole;  osteotomy 
of  the  tibia  and  fibula  above  the  ankle  is  seldom  em- 
ployed. Tarsectomy  has  been  performed  in  various 
ways,  one  or  more  of  the  tarsal  bones  being  removed, 
according  to  different  operators.  Perhaps  the  best  plan  is  to  re- 
move a  wedge  of  bone  with  the  base  outwards  and  of  suflicient  size 
to  correct  the  deformity.  An  incision  is  made  over  the  most  promi- 
nent portion  of  the  tarsus,  the  tendons  and  soft  parts  retracted, 


Fig.  553. 
Thomas   club- 
foot wrench. 


63 


994  MANUAL    OF   SURGERY 

and  the  bone  removed  with  a  chisel,  without  respect  to  the  individual 
bones  or  joints.  Bone  transplantation  has  been  employed  with  suc- 
cess. The  scaphoid  is  split  into  anterior  and  posterior  halves,  and 
a  wedge  of  bone  taken  from  the  tibia  or  the  cuboid  forced  into  the 
split.  In  paralytic  cases  tendon  or  nerve  transplantation  many 
indicated.  "The  outer  half  of  the  tendo  Achillis  may  be  inserted 
into  the  distal  end  of  both  peronei.  The  extensor  longus  hallucis 
or  the  outer  half  of  the  tibialis  anticus  may  be  passed  across  the  foot 
under  the  other  tendons  to  be  fastened  to  the  periosteum  of  the 
cuboid  bone"  (Le  Breton).  The  anterior  tibial  nerve  and  the  bran- 
ches to  the  tibialis  anticus  may  be  transplanted  into  the  musculo- 
cutaneous. Arthrodesis  of  the  calcaneo-cuboid  joint  also  may  be 
used  in  these  cases. 

Talipes  equinus  is  usually  the  result  of  paralysis  of  the  extensor 
muscles,  and  is  rare  as  a  congenital  deformity;  the  patients  walk  on 
the  toes,  and  in  the  worst  cases  on  the  dorsum  of  the  foot.  The 
tendo  Achillis  and  the  tissues  of  the  sole  of  the  foot  are  shortened. 
The  operative  measures  for  its  correction  are  division  or  lengthening 
of  the  tendo  Achillis,  or  in  more  severe  cases  removal  of  the  astra- 
galus or  a  wedge-shaped  section  of  the  tarsus.  Nerve  transplanta- 
tion as  for  equino-varus,  or  the  transplantation  of  a  portion  of  the 
tendo  Achillis  to  the  tibialis  anticus  or  extensor  communis  digitorum 
may  be  employed.  Alter  correction  arthrodesis  of  the  ankle  joint 
may  be  performed. 

Talipes  calcaneus  may  be  congenital  or  acquired.  The  foot  is 
drawn  upwards  and  the  patient  walks  on  the  heel.  It  may  require 
division  of  the  extensor  tendons,  shortening  of  the  tendo  Achillis, 
transplantation  of  the  peronei  into  the  os  calcis,  astragalectomy,  or 
arthrodesis  of  the  ankle  joint. 

Talipes  valgus  (Fig.  554)  is  an  abduction  and  eversion  of  the  foot 
with  flattening  of  the  sole.  It  may  be  combined  with  equinus  or 
calcaneus.  The  acquired  form  is  synonymous  with  flat-foot,  under 
which  the  treatment  will  be  discussed. 

Talipes  varus  (Fig.  555),  or  adduction  and  inversion  of  the  foot, 
is  treated  as  equino-varus,  excepting  the  division  of  the  tendo  AchilHs. 

Flat-foot,  or  pes  planus  {splay-foot,  acquired  or  spurious  valgus), 
is  a  flattening  of  the  arch,  usually  with  abduction  and  eversion  of  the 
foot.  The  causes  include  all  those  conditions  which  induce  a  dispro- 
portion between  the  weight  of  the  body  and  the  strength  of  the  mus- 
cular and  ligamentous  tissues  controlling  the  foot,  and  diseases  or 
injuries  which  alter  the  relation  or  shape  of  the  bones.  Among  these 
conditions  are  improperly  fitting  shoes,  prolonged  standing,  rapid 


EXTREMITIES  995 

increase  in  weight,  general  ill  ]icalth,  prolonged  disuse  of  the  foot 
resulting  in  muscular  weakness,  infantile  or  other  form  of  paralysis, 
rickets,  injury  (particularly  Pott's  fracture),  and  arthritis,  especially 
of  gonorrheal  origin. 

Symptoms  may  be  absent  in  a  well-marked  case,  severe  in  a  case 
in  which  the  deformity  is  slight  or  absent.  Pain,  particularly  after 
using  the  foot,  is  most  marked  in  the  sole  and  the  mid  tarsal  joint,  but 
occurs  also  in  other  portions  of  the  foot,  occasionally  being  reflected 
up  the  limb  even  to  the  lumbar  region,  and  sometimes  associated 
with  muscular  spasm.  The  foot  loses  its  normal  flexibility,  and 
tenderness  exists  over  the  points  of  the  ligamentous  attachments. 
The  gait  is  shuffling  and  there  maybe  some  swelling,  which  frequently 
leads  to  an  incorrect  diagnosis  of  rheumatism.  The  deformity  (Fig. 
554)  is  quite  obvious  in  well-marked  cases  and  is  accentuated  when 
the  patient  stands.  The  inner  border  of  the  foot  is  lengthened  and 
rests  on  the  ground,  and  the  internal  malleolus  and  head  of  the  as- 
tragalus are  more  prominent  than  usual.     The  plantar  ligaments  and 


Fig.  554. — Talipes  valgus.     (Gould.)  Fig.  555. — Talipes  varus.     (Gould.) 

muscles  are  stretched,  the  tibialis  posticus  weakened,  and  the  pero- 
nei  contracted.  An  impression  of  the  weight  bearing  portion  of  the 
sole  may  be  obtained  by  having  the  patient  step  on  cardboard 
covered  with  lamp  black. 

The  treatment  in  static  cases,  i.e.,  those  due  to  disproportionate 
w^eight,  is  to  strengthen  the  muscles,  by  means  of  massage,  electri- 
city, and  exercises,  such  as  rising  on  the  toes,  and  walking  with  the 
foot  in  a  varus  position.  By  wedging  the  inner  edges  of  the  heels 
and  soles  of  the  shoes,  pronation  can  be  overcome;  soft  felt  pads  can 
be  moulded  to  support  the  longitudinal  and  anterior  arches  of  the 
foot  and  attached  to  the  insoles  of  the  shoes.  When  the  symptoms 
have  disappeared  the  artificial  support  should  be  gradually  discon- 
tinued. When  the  foot  is  too  tender  for  the  use  of  shoes  the 
patient  may  rest  in  bed  or  have  a  plaster  cast  applied.  In  some 
cases  the  eversion  is  so  marked  as  to  require  a  steel  bar  running  up 
the  outer  side  of  the  leg,  and  supphed  with  a  strap,  which  passes 
around    the    internal    malleolus    and    pulls   the   ankle  out.     Sup- 


996  MANUAL   OF   SURGERY 

ports  are  generally  useless  unless  the  deformity  can  be  cor- 
rected. When  the  foot  is  fixed  in  deformity,  the  patient  should  be 
anesthetized,  the  deformity  overcorrected  with  the  hands  or  the  club- 
foot wrench,  and  a  plaster  cast  applied,  a  support  being  used  when 
the  pain  has  disappeared.  In  paralytic  cases  nerves  may  be  trans- 
planted as  in  equino-varus.  The  peroneus  brevis  may  be  passed 
under  the  tendo  Achillis  and  attached  to  the  scaphoid,  while  the 
peroneus  tertius  may  be  attached  to  the  same  point  after  being 
passed  beneath  the  anterior  tendons.  The  extensor  longus  pollicis 
or  the  tibialis  anticus  may  be  passed  through  a  hole  bored  in  the 
scaphoid  and  turned  back  and  sutured  to  the  periosteum.  The 
peroneus  longus  has  been  transplanted  to  the  tibialis  posticus.  When 
the  obstacle  to  reduction  is  osseous,  a  wedge  of  bone  may  be  removed 
from  the  inner  side  of  the  tarsus.  Other  bone  operations  are  osteo- 
tomy of  the  neck  of  the  os  calcis  and  astragalus,  removal  of  the 
scaphoid,  supramalleolar  osteotomy,  longitudinal  section  of  the  os 
calcis  with  displacement  downwards  of  the  pos- 
terior fragment,  and  bone  transplantation,  a 
wedge-shaped  piece  of  the  scaphoid  being  excised, 
thus  shortening  the  inner  side  of  the  foot,  and 
driven  into  an  osteotomy  wound  in  the  forward 
part  of  the  os  calcis,  thus  lengthening  the  outer 
border  of  the  foot. 
^''''  ■"(g7uMo'^''"''  P®s  cavus,  or  hollow  foot  (Fig.  556)^15  the  re- 
verse of  flat-foot.  It  is  rarely  congenital,  being 
usually  the  result  of  anterior  poliomyelitis  or  the  wearing  of  short 
or  ill  fitting  shoes.  The  most  marked  cases  occur  in  Chinese  women, 
from  bandaging.  The  treatment  is  the  use  of  a  properly  fitting  shoe, 
with  a  flat  steel  plate  in  the  sole  and  a  strap  running  over  the  arch  of 
the  foot.  The  severer  forms  require  division  of  the  plantar  fascia. 
Metatarsalgia,  or  Morton's  disease,  is  severe  neuralgic  pain 
beginning  on  either  side  of  the  distal  end  of  the  fourth  metatarsal 
bone  and  passing  up  the  foot  and  often  up  the  leg.  It  is  caused, 
by  a  pinching  of  the  digital  nerves  between  the  heads  of  the  third 
and  fourth  or  fourth  and  fifth  metatarsal  bones,  which  have  become 
displaced  as  the  result  of  badly  fitting  shoes.  The  transverse  arch 
formed  by  the  distal  ends  of  the  metatarsal  bones  is  flattened  and 
the  foot  broadened;  there  may  or  may  not  be  flat-foot.  The  pain 
usually  comes  on  when  walking  and  is  often  so  severe  that  the  pati- 
ent immediately  removes  the  shoe  and  rubs  the  foot;  it  can  often  be 
induced  by  rolling  the  metatarsal  bones  one  over  the  other.  The 
treatment  is  the  application  of  a  felt  pad  to  correct  the  flattened 


EXTREMITIES  997 

anterior  arch,  vida  supra,  and  the  use  of  properly  litting  shoes. 
Intractable  cases  can  be  cured  only  by  resection  of  the  head  of  the 
fourth  metatarsal  bone,  or  by  excision  of  the  superficial  branch  of 
the  external  plantar  nerve. 

Hallux  valgus  is  an  outward  deviation  of  the  great  toe  produced 
by  short  tight  or  pointed  shoes  and  stockings.  It  exists  in  a  slight 
degree  in  most  civilized  people  and  the  most  severe  forms  are 
commonly  seen  in  later  life.  The  head  of  the  first  metatarsal  is 
uncovered,  and  often  becomes  enlarged  as  the  result  of  chronic  peri- 
ostitis. A  bursa  may  form  in  this  situation  {bunion),  which  may  be- 
come inflamed;  should  suppuration  occur  the  joint  may  be  invaded 
and  disorganized.  The  treatment  in  early  cases  is  the  fitting  of 
straight-last,  round- toed  shoes  and  the  application  to  the  inner 
side  of  the  foot  of  a  hard  rubber  splint,  to  which  the  toe  is 
bandaged,  or  the  use  of  a  metal  partition  attached  to  the  sole  of  the 


Fig.   557. — (Weir,  "Annals  of  Surgery.") 

shoe  and  projecting  between  the  first  and  second  toes.  An  inflamed 
bunion  is  treated  like  acute  bursitis;  a  bunion  plaster,  i.e.,  a  pad 
with  a  central  opening,  may  be  applied  to  relieve  pressure.  Perman- 
ent relief-is  obtained  by  excision  of  the  bursa,  and  correction  of  the 
hallux  valgus,  which  in  advanced  cases  can  be  accomplished  only 
by  operation.  This  may  be  an  osteotomy  of  the  metatarsal  bone, 
an  excision  of  the  metatarso-phalangeal  joint,  or  a  shaving  off  of  the 
exostosis  on  the  inner  side  of  the  head  of  the  metatarsal  bone.  In 
addition  to  the  last  procedure,  Weir  divides  the  outer  portion  of  the 
capsular  ligament  and  transfers  the  dorsal  tendon  to  the  periosteum 
on  the  inner  side  of  the  base  of  the  first  phalanx  (Fig.  557).  After 
excising  the  joint  and  the  exostosis.  Mayo  swings  a  flap  consisting 
of  the  subcutaneous  tissues  and  the  bursa,  into  the  defect  between 
the  bones,  thus  re-establishing  the  joint.'  A  similar  result  may  be 
obtained,  if  the  bursa  must  be  excised,  by  filling  the  new  joint  with 
fat. 


998  MANUAL    OF   SURGERY 

Hallus  rigidus  is  an  arthritis  of  the  metatarso-phalangealarticu- 
iation,  the  result  of  flat-foot,  defective  shoes,  or  injury,  and  terminat- 
ing in  ankylosis.  The  treatment  is  removal  of  the  cause,  with  local 
applications  as  for  arthritis.  In  old  cases,  particularly  if  ankylosis 
occurs  in  a  vicious  position,  arthroplasty  may  be  performed. 

Hammer-toe  is  a  permanent  hyperextension  of  the  first,  and 
flexion  of  the  second  and  third  phalanges.  The  congenital  form 
is  probably  due  to  shortening  of  the  lateral  digital  processes  of  the 
plantar  fascia.  It  may  be  caused  by  short  shoes  or  be  associated 
with  hallux  valgus,  talipes  equinus,  or  pes  cavus.  It  also  follows 
paralysis  of  the  interossei  and  lumbricales,  corresponding  to  a  similar 
deformity  of  the  fingers  after  ulnar  paralysis.  Corns  or  bursae  may 
form  over  the  points  exposed  to  pressure,  and  walking  becomes  pain- 
ful and  difficult.  The  treatment  in  the  mildest  form  is  the  wearing 
of  proper  shoes,  the  application  of  a  splint,  preceded,  if  necessary,  by 
division  of  the  contracted  fascia  and  forcible  correction.  When  more 
severe,  it  will  be  necessary  to  excise  the  distal  end  of  the  first  phalanx 
and  divide  the  extensor  tendon.  In  the  worst  cases  amputation  will 
be  required. 

Achillodynia  is  a  term  which  has  been  applied  to  two  separate 
conditions,  (i)  Post-calcaneal  bursitis,  or  Albert's  disease,  causes 
a  tender  swelling  between  the  os  calcis  and  tendo  Achillis,  and  may 
follow  an  injury,  a  strain,  or  prolonged  walking  or  skating.  Some 
cases  are  due  to  an  exostosis  of  the  os  calcis.  The  treatment  is  rest 
of  the  foot  and  the  use  of  the  measures  indicated  in  bursitis.  Opera- 
tion may  be  required  for  an  exostosis.  (2)  Synovitis  of  the  tendo 
Achillis  may  follow  the  same  conditions,  or  arise  spontaneously  in 
the  gouty  or  rheumatic.  Pain  and  swelling  are  most  marked  at  the 
level  of  the  top  of  the  shoe,  and  soft  crepitus  may  sometimes  be 
obtained  on  flexing  or  extending  the  foot.  The  treatment  is  that  of 
tenosynovitis,  with  the  use  of  the  salicylates  in  the  rheumatic. 

Painful  heel  {policeman^ s  heel)  is  charactrized  by  pain  and  tender- 
ness on  the  under  surface  of  the  heel.  It  may  be  caused  by  strain, 
periostitis,  flat-foot,  inflammation  of  the  bursa  beneath  the  os  calcis, 
or  an  exostosis,  hence  the  necessity  for  a  radiograph  in  all  doubtful 
cases.     The  treatment  necessarily  varies  with  the  cause. 

Aside  from  superficial  obvious  lesions,  e.g.,  corns,  wounds,  ulcers, 
etc.,  and  in  addition  to  the  various  conditions  mentioned  above, 
painful  feet  may  be  caused  by  gout,  rheumatism,  cardiac  or  renal 
disease,  fteurasthenia,  neuritis,  neuroma  or  other  tumors,  inflamm- 
atory affections  of  the  bones,  and  diseases  of  the  ovary,  prostate,  or 
rectum.     Non-deforming  club-foot  causes  pain  in  the  foot,  leg,  and 


EXTREMITIES  999 

ankle,  and  is  supposed  to  be  due  to  an  alteration  in  the  articular 
surfaces,  the  result  of  injury,  arthritis,  habitual  malposition,  or 
anterior  poHomyelitis.  The  foot  cannot  be  flexed  beyond  a  right 
angle.  Erythromelalgia  is  a  curious  nervous  disorder  in  which  there 
are  redness,  sweUing,  and  burning  pain,  increased  by  heat  and  im- 
mediately relieved  by  cold. 

Perforating  ulcer  of  the  foot  [mal- per  J  or  ant)  is  most  frequently 
seen  beneath  the  head  of  the  first  or  fifth  metatarsal  bone.  As  a 
rule  a  corn  or  callosity  first  appears,  suppuration  takes  place  beneath 
this,  and  a  sinus  results,  the  opening  being  surrounded  by  thickened 
epidermis;  the  sinus  deepens,  and  if  allowed  to  progress  unchecked, 
the  bones  and  joints  may  be  destroyed..  The  discharge  is  scanty 
and  pain  frequently  sHght  or  absent.  The  cause  of  perforating  ulcer 
is  usually  anesthesia  of  the  sole  of  the  foot,  which  permits  repeated 
or  long  continued  irritation  without  the  individual's  knowledge. 
It  may  be  found  in  many  diseases,  conspicuous  among  which  are 
leprosy,  tabes  dorsalis,  syringomyelia,  and  peripheral  neuritis  the 
result  of  alcohol,  syphilis,  or  diabetes;  it  may  result  also  from  spina 
bifida  and  from  injury  of  the  spinal  cord  or  nerves.  In  rare  instances 
it  may  follow  epithelioma,  a  neglected  corn,  or  other  purely  local 
lesion,  and  in  these  cases  pain  may  be  severe. 

The  treatment  is  relief  of  pressure  by  confining  the  patient  to  a 
chair,  removal  of  the  thickened  epidermis  after  poulticing  or  soaking 
the  foot  in  warm  water,  and  disinfection  and  drainage  of  the  sinus; 
the  wound  may  then  be  stimulated  by  balsam  of  Peru,  or  weak  solu- 
tions of  silver  nitrate  or  copper  sulphate.  Good  results  have  followed 
stretching  of  the  tibial  or  the  plantar  nerves.  In  recalcitrant  cases 
the  ulcer  should  be  excised  and  necrotic  bone  removed.  When  the 
foot  is  extensively  involved  amputation  may  be  necessary.  The 
cause  of  the  condition  should,  of  course,  be  removed  if  possible. 

AMPUTATIONS 

Amputation  as  applied  to  the  extremities  signifies  the  removal  in 
continuity  of  the  whole  or  a  portion  of  a  limb.  If  through  a  joint  it  is 
known  as  a  disarticulation.  The  chief  considerations  in  regard  to 
the  operation  are  (a)  its  indications,  (b)  the  time,  and  (c)  the  site  at 
which  it  should  be  performed,  and  (d)  the  method  of  proceeding. 

a.  The  indications  for  amputation  are  (i)  to  save  life,  e.g.,  in 
extensive  crushes,  virulent  infections,  gangrene,  septic  diseases  of 
bone,  tumors,  and  aneurysms;  and  (2)  to  provide  for  the  fitting  of 
useful  artificial  supports  when  the  limb  is  functionless  from  disease 


lOOO  MANUAL   OF   SURGERY 

or  deformity.  To  amputate  or  not  to  amputate  is  a  question  which 
often  taxes  the  surgeon's  judgment  to  the  utmost,  as  absolute  rules 
cannot  be  formulated.  The  age  and  general  condition  of  the  patient 
may  be  such  as  to  necessitate  amputation,  which  under  other  circum- 
stances would  be  inadvisable.  Furthermore,  a  laborer  who  must 
support  a  large  family  can  often  be  more  quickly  and  better  prepared 
to  meet  life's  responsibilities  with  an  artificial  limb  than  with  a  badly 
crippled  extremity, which  to  his  more  furtunate  brother  is  an  incon- 
venience only.  In  injuries  the  principal  questions  to  be  answered  are : 
(i)  Will  the  blood  supply  be  adequate  to  prevent  gangrene;  (2)  is  the 
injury  to  the  nerves  and  muscles  so  great  that  a  useful  limb  cannot 
be  obtained;  (3)  can  infection  be  prevented  or  kept  under  control? 
I.  Laceration  of  the  main  artery  or  vein  alone  is  not  an  indication 
for  amputation,  as  either,  indeed  both,  may  be  sutured  or  even  tied 
without  gangrene  following,  providing  the  collateral  vessels  are 
intact.  If  both  artery  and  vein  require  ligation,  however,  and  the 
collateral  vessels  also  are  damaged,  amputation  must  be  performed. 
Moszkowitz  tests  the  efficiency  of  the  circulation  by  elevating  the 
limb,  applying  a  tourniquet,  then  lowering  the  limb  and  after  five 
minutes  removing  the  constrictor.  If  the  circulation  is  active,  the 
whole  limb  becomes  hyperemic  in  a  few  seconds.  Parts  which 
remain  anemic  are  devitalized,  those  which  improve  in  color  very 
slowly  will  probably  become  gangrenous.  Matas,  in  order  to  ascer- 
tain the  condition  of  the  collateral  circulation,  maintains  the  pressure 
on  the  artery  after  removing  the  tourniquet.  Sandrock  scrubs  the 
limb  vigorously,  thus  inducing  hyperemia  if  the  part  is  adequately 
nourished.  If  the  limb  is  of  normal  color  and  temperature  below  the 
wound,  if  the  peripheral  ends  of  the  artery  and  the  vein  bleed,  and  if, 
in  case  the  artery  alone  is  injured,  congestion  can  be  produced  by 
compressing  the  main  vein,  the  collateral  circulation  is  capable  of 
supporting  the  life  of  the  limb.  2.  Nerves  and  muscles  may  be 
■brought  together  in  suitable  cases,  but  they  are  often  so  extensively 
damaged  that  they  either  cannot  be  approximated  or  repair  cannot 
be  expected.  Extensive  loss  of  skin  in  itself  is  rarely  an  indication 
for  amputation.  3.  Infection  is  practically  never  an  indication  for 
primary  amputation;  although  a  finger  has  been  amputated  im- 
mediately after  a  bite  by  a  venomous  snake  or  after  a  known  infection 
with  very  virulent  organisms.  Unless  amputation  is  positively 
demanded,  e.g.,  in  pulpification  of  the  whole  limb  or  a  segment 
thereof,  one  is  always  justified  in  making  an  effort  to  preserve  the 
part  by   careful   disinfection   and   free  drainage. 

b.  According  to  the  time  at  which  an  amputation  is  performed  it 


EXTREinXIES  .  lOOI 

is  designated  primary,  intermediate,  or  secondary.  Primary  ampu- 
tation, i.e..  during  the  first  24  hours  after  the  injury,  should,  as  a  rule, 
be  postponed  until  shock  has  subsided,  the  hemorrhage  being  tem- 
porarily stayed  by  applying  a  tourniquet  as  close  as  possible  to  the 
point  at  which  the  muscles  and  bone  are  crushed.  The  tissues  thus 
compressed  are  already  so  devitalized  that  they  would,  in  any  event, 
be  removed  with  the  limb,  hence  the  tourniquet  is  harmless  and 
should  remain  in  place  until  after  the  amputation,  a  second  one  being 
adjusted  at  a  higher  level  to  control  bleeding  during  the  operation. 
An  intermediate  amputation  is  one  performed  after  24  hours,  and 
within  the  first  few  days,  generally  for  gangrene  or  extensive  cellu- 
litis, occasionally  for  bleeding.  Secondary  amputation,  i.e.,  after 
a  number  of  days,  may  be  required  for  secondary  hemorrhage,  osteo- 
myelitis, chronic  sepsis,  exhaustion,  or  amyloid  disease  or  to  remove 
a  useless  limb  after  healing  has  occurred. 

c.  The  site  or  level  at  which  a  part  is  to  be  removed  to  secure  the 
best  result  is  pointed  out  in  the  description  of  "  Special  Amputations. " 
Not  always  is  the  longest  stump  attainable  the  best  adapted  for  an 
artificial  Umb.  Only  in  amputations  through  the  hand  must  one 
preserve  every  viable,  or  even  doubtful,  fragment  of  tissue.  Infec- 
tion, actual  or  threatened,  may  interfere  with  the  principle  of  prosthe- 
sis. Although,  according  to  this  principle,  disarticulation  at  the 
^vTist,  elbow,  ankle,  and  knee  is  generally  to  be  avoided,  it  is  often 
better  when  amputating  for  virulent  infection  to  go  through,  rather 
than  above  or  below,  these  joints,  in  order  to  avoid  exposing  the  bone 
to  bacterial  invasion.  The  guillotine  amputation,  to  be  described 
later,  could  be  justified  only  as  life  saving  measure  in  the  presence  of 
infection.  In  addition  to  usefulness  and  infection  esthetic  reasons 
may  influence  the  site  of  amputation,  e.g.,  in  supernumerary  digits, 
and  sometimes  after  an  injury  to  the  hand,  when  the  patient,  a 
woman,  prefers  symmetry  to  strength. 

d.  The  operation  is  preceded  by  disinfection,  which  in  accident 
cases  can  be  thoroughly  performed  only  after  the  induction  of  anes- 
thesia. The  operator  stands  to  the  rightof  the  limb,  which  isbrought 
to  the  edge  of  the  table  and  held  by  an  extra  assistant. 

Preliminary  control  of  hemorrhage  is  secured  by  elevating  the 
limb  for  several  minutes,  in  order  to  allow  the  blood  to  drain  into 
the  vessels  of  the  body,  and  appl^dng  an  Esmarch  band  fFig.  121)  or 
other  form  of  tourniquet  (Fig.  122)  above  the  site  of  amputation. 
In  certain  regions  (hip  and  shoulder)  sHpping  downwards  may  be 
prevented  by  long  pins  thrust  through  the  tissues  below  the  band, 
by  sutures,  or  by  a  bandage  passing  beneath  the  band  and  around 


I002 


MANUAL   OF    SURGERY 


the  trunk.  When  elastic  constriction  is  inadvisable  (atheroma,  etc.) 
or  inapplicable  (interscapulo-thoracic  amputation,  etc.),  the  main 
v'essels  may  be  occluded  by  digital  pressure,  or  exposed  by  a  pre- 
Hminary  incision  and  clamped  or  tied. 

Division  of  the  tissues  must  be  so  made  that  there  will  be  suffi- 
cient muscle  to  cover  the  bone,  and  ample  skin  to  cover  the 
muscles,  the  scar  being  so  situated  as  not  to  be  exposed  to  pressure. 
As  the  tissues  subsequently  contract,  flaps  which  fit  snugly  are  too 
short.  Formerly  made  by  entering  a  long  knife  close  to  the  bone 
and  cutting  from  within  outwards  {transfixion) ,  flaps,  at  the  present 
time,  are  dissected  from  without  inwards,  as  anesthesia  has  removed 
the  necessity  for  great  haste,  and  it  is  important  to  di\ide  the 
vessels  and  nerves  transversely  rather  than  obliquely.  The  manner 
in  which  the  flaps  are  shaped  is  described  below.     After  retracting 


Pig.   558. — Circular  amputation,  showing 
application  of  two-tailed  muslin  retractor. 


Pig.  559. — Amputation  through 
metatarsus,  showing  application  of 
six-tailed  muslin  retractor. 


the  soft  parts  the  periosteum  is  incised  circularly  around  the  bone, 
at  least  one  half  inch  above  the  proposed  level  of  division  of  the 
bone.  The  soft  parts  are  now  drawn  out  of  harm's  way  by  means 
of  a  piece  of  muslin  with  a  slit  in  it  for  with  two  or  more  slits  in  it 
if  there  are  two  or  more  bones.  Figs.  558,  559),  and  the  hone 
sawed  transversely.  The  nail  of  the  left  thumb  is  pressed  against 
the  bone  just  above  the  saw-line  and  the  blade  of  the  saw  steadied 
by  the  knuckle  of  the  thumb.  The  saw  is  then  lightly  drawn  from 
heel  to  point  several  times,  so  as  to  form  a  groove,  after  which,  as 
there  is  less  danger  of  injury  to  the  soft  parts  from  slipping  of  the 
of  the  saw,  a  to-and-fro  motion  is  employed,  but  never  with  great 
force.  When  the  section  is  nearly  completed  the  strokes  should 
become  short  and  very  light.  Any  spicules  or  bony  irregularities 
are  removed  with  rongeur  forceps.     Nerves  and  tendons  are  drawn 


EXTREMITIES  IOO3 

out  a  little  way  and  cut  off  short,  thus  preventin*!;  their  inclusion  in 
the  cicatrix.  In  order  to  avoid  the  formation  of  neuromata,  each 
large  nerve  may  be  exsected  by  a  V-shaped  incision,  followed  by 
suture  of  the  neural  flaps;  the  end  of  each  nerve  may  be  turned  back 
and  sutured  to  the  trunk;  the  ends  of  the  nerves  may  be  sutured 
together  or  covered  with  fat;  or,  as  mentioned  above,  the  nerves  may 
be  cut  at  a  high  level  and  allowed  to  retract.  If  the  amputation 
has  been  performed  skillfully  there  will  be  little  need  for  trimming 
away  tags  or  shreds  of  muscle  and  fascia.  The  principles  recited 
above  are  considered  sound  by  most,  but  not  all,  surgeons.  A  few 
believe  that  retention  of  the  deep  fascia  is  liable  to  cause  sloughing. 
Others  fashion  the  flaps  without  muscular  tissue,  because  it  subse- 
quently atrophies. 

Permanent  control  of  hemorrhage  is  attained  by  isolating  the 
large  vessels,  and  tying  each  with  catgut.  The  tourniquet  is  then 
removed,  and  the  smaller  vessels  caught,  and  ligated  with  catgut. 
Capillary  oozing  may  be  controlled  by  pressure  with  gauze,  or  by 
very  hot  water;  bleeding  from  the  bone  which  persists  after  the  use  of 
these  expedients  may  be  arrested  with  crushed  muscle  or  bone 
wax. 

Closure  of  the  wound  should  obliterate  all  dead  spaces.  The 
muscles  are  stitched  with  catgut,  the  skin  with  silkworm  gut. 
Drainage  is  not  required  if  the  wound  is  dry  and  clean.  If  oozing 
continues,  gauze  or  a  rubber  tube  may  be  inserted  between  the  lips 
of  the  most  dependent  part  of  the  wound,  through  which  a  suture 
is  passed  but  not  tied.  After  24  or  48  hours  the  drain  is  removed 
and  the  suture  tied.  Drainage  for  infection  must  be  maintained 
until  the  healing  process  is  almost  completed.  After  applying  the 
dressing,  the  stump  is  firmly  bandaged  in  such  a  way  as  not  to  drag 
on  the  flaps;  then  bound  to  a  splint  which  projects  beyond  the  end 
of  the  stump,  thus  protecting  it  from  injury;  elevated  on  a  pillow  in 
order  to  minimize  oozing;  and  covered  with  a  cradle,  which  supports 
the  bed  clothing.  The  sutures  are  removed  at  the  end  of  ten  days, 
after  which  tension  on  the  line  of  union  is  relieved  by  means  of 
strips  of  sterilized  adhesive  plaster. 

The  fundamental  types  of  amputation,  designated  according  to 
the  shape  of  the  incision  in  the  soft  parts,  are  the  circular,  the  oval, 
the  racquet,  and  the  flap  methods. 

In  the  circular  amputation  the  skin  and  the  subcutaneous  tissues 
are  divided  around  the  whole  circumference  of  the  limb,  at  a  distance 
below  the  level  of  the  intended  saw-line,  equal  to  three-fourths  of  the 
diameter  of  the  limb  at  the  saw-line.     The  skin  and  superficial 


I004 


MANUAL   OF    SURGERY 


fascia  are  dissected  back  like  a  cuff,  the  superficial  muscles  divided 
at  the  level  of  the  retracted  skin,  and  the  deep  muscles  divided  at  the 
edge  of  the  retracted  superficial  muscles,  so  that  the  cut  surfaces 
resemble  a  funnel  (Fig.  560).  The  deep  muscles,  the  superficial 
muscles,  and  the  skin  are,  in  turn,  sutured,  either  transversely  or 
anteroposteriorly,  the  scar  being  situated  on  the  end  of  the  stump. 
The  method  may  be  employed  when  the  bone  is  evenly  surrounded 
by  muscles,  e.g.,  in  the  arm  and  the  thigh.     It  is,  simple,  quick, 


Fig.  560. — Circular  amputation.  A,  level 
of  skin  incision;  B,  level  of  section  of  super- 
ficial muscles ;  C,  of  deep  muscles;  D,  saw 
line. 


A  CD 

Fig.  561.- — Oval  amputation.  AB,  skin 
incision;  C,  level  of  section  of  muscles;  D, 
saw-line.  At  the  completion  of  the  opera- 
tion A  is  sutured  to  B. 


sacrifices  less  of  the  soft  parts  than  other  methods,  supplies  a  thick 
covering  for  the  bone,  and  does  not  endanger  the  blood  supply  to 
this  covering,  but  it  has  a  limited  range  of  applicability,  produces 
a  funneled  wound  that  may  render  exposure  of  the  bone  at  the  saw- 
line  difficult,  and,  owing  to  the  retraction  of  the  muscles,  is  some- 
times followed  by  a  conical  stump. 


Fig.  562.- — Racquet  amputations.  A, 
transverse  racquet  incision;  B,  oblique 
racquet  incision;  D,  saw-line. 


Fig.    563. — Flap  amputations.      A,   single 
long  flap;  B,  double  equal  flaps. 


In  the  oval  method  an  elliptical  incision  is  made  around  the  limb, 
through  the  skin  and  the  subcutaneous  tissues,  the  upper  end  of  the 
ellipse  being  just  above  the  saw-line,  and  the  lower  end  at  a  distance 
below  the  saw-line  equal  to  one  and  one-half  diameters  of  the  limb  at 
the  saw-line.  The  distal  portion  of  the  ellipse  is  dissected  up,  and  the 
muscles  divided  circularly  a  little  below  the  proximal  end  of  the  skin 
incision,  or  the  muscles  underlying  the  distal  half  of  the  ellipse  may 
be  divided  in  the  plane  of  the  oval  and  those  on  the  opposite  side  of 
the  limb  divided  circularly  just  below  the  level  of  the  saw-line. 


EXTREMITIES  "  IOO5 

The  operation  is  completed  by  suturing  the  free  convex  border  of  the 
cutaneous  incision  to  the  upper  concave  margin  (Fig.  561),  conse- 
quently the  scar  is  on  the  side  of  the  stumj:).  This  method  is  em- 
ployed chiefly  for  disarticulation  of  the  elbow  or  the  wrist.  It  has 
the  advantages  and  disadvantages  of  amputation  by  a  long  single 
flap. 

The  racquet  method  (Fig.  562)  consists  of  a  straight  incision  in  the 
axis  of  the  limb,  joining  a  circular  or  oval  incision  around  the  limb, 
the  angles  formed  by  the  junction  of  the  incisions  being  rounded. 
The  muscles  beneath  the  straight  incision  are  divided  or  separated 
down  to  the  bone,  and  those  beneath  the  circular  or  the  oval  incision 
divided  at  the  level  of  the  retracted  skin.  The  wound  is  closed  in  its 
long  axis,  so  that  the  scar  runs  across  the  end  of  the  stump  and  up  one 
side.  The  racquet  method  is  often  employed  for  disarticulations. 
If  desirable  the  parts  may  be  explored  through  the  longitudinal 
incision  before  deciding  on  amputation,  and  through  the  same  inci- 
sion the  main  vessels  can  be  secured  before  removing  the  limb. 


Pig.  564. — Modified  flap  and  circular  amputation  of  the  forearm. 

Lateral  or  anteroposterior  flaps  may  consist  merely  of  skin  and 
subcutaneous  tissue,  or  of  all  the  tissues,  the  muscles  being  cut 
obliquely  from  the  line  of  the  retracted  cutaneous  incision,  to  a  point 
on  the  bone  at  a  distance  below  the  saw-line  equal  to  a  little  more 
than  the  diameter  of  the  bone  at  the  saw-line.  The  flaps  may 
be  single  or  double  (Fig.  563),  and  of.  various  sizes  and  shapes, 
according  to  the  exigencies  of  the  case,  but  their  bashes  should 
be  half  the  circumference  of  the  limb  in  width,  and  the  length  of 
single  flaps,  or  the  combined  length  of  double  flaps,  should  be  one  and 
one-half  diameters  of  the  limb  at  the  saw-line.  The  scar  is  situated 
to  the  side  of  the  stump  after  an  amputation  by  a  single  flap,  on  the 
end  and  the  sides  after  an  amputation  by  equal  flaps,  and,  according 
to  the  degree  of  inequahty,  on  the  side,  or  partly  on  the  side  and 
partly  on  the  end,  after  an  amputation  by  unequal  flaps.  The  flap 
method  may  be  employed  in  any  region,  permits  easy  exposure  of 
the  bone  at  the  saw-line,  and  gives  a  more  shapely  stump  than  the 
circular  amputation,  but  it  sacrifices  more  of  the  limb,  produces  a 
larger  wound,  with  -the  muscles  and  the  vessels  cut  obliquely,  and 
may  not  adequately  provide  for  the  nourishment  of  the  flaps  if  they 


IOo6  MANUAL    OF    SURGERY 

are  long.  Hence  many  surgeons,  in  order  to  combine  the  merits 
of  the  flap  and  the  circular  amputations  employ,  when  possible,  the 
modified  flap  and  circular  method,  which  consists  of  two  rectangular 
flaps,  with  rounded  corners,  made  on  opposite  sides  of  the  limb. 
The  skin  and  the  subcutaneous  tissues  are  reflected,  and  the  muscles 
divided  as  in  the  circular  amputation  (Fig.  564).  Osteoplastic  flaps 
are  described  with  amputations  of  the  leg. 

The  guillotine,  or  flapless  amputation,  was  revived  during  the 
war  to  save  life  by  saving  time  and  combating  infection,  especially 
gas  gangrene.  The  skin  was  divided  circularly,  the  muscles  were 
severed  at  the  level  of  the  retracted  skin,  and  the  bone  was  sawn  at 
the  level  of  the  retracted  muscles,  thus  making  the  end  of  the  stump 
a  plane  surface.  To  prevent  further  retraction  of  the  soft  parts 
extension  by  means  of  adhesive  plaster  was  applied  to  the  skin  of  the 
stump,  in  much  the  same  way  as  traction  in  made  in  fractures  of  the 
thigh,  the  strips  of  plaster,  however,  being  carried  down  to  a  metal 
ring,  larger  than  the  stump,  and  the  cord  and  weight  being  attached 
to  the  ring.  "The  apparatus  is  very  like  the  horn  of  a  gramophone, 
and  in  the  middle  the  stump  is  easily  accessible  for  dressing"  (Kelly). 
After  the  infection  had  been  conquered  the  raw  surface  could  be 
covered  by  a  plastic  operation  or  a  secondary  amputation  performed. 
The  method  was  condemned  by  Gibbon  and  others  actively  en- 
gaged at  the  front,  and  is,  we  hope,  now  of  historic  interest  only. 

A  stump  when  healed  should  be  firm,  symmetric,  well  covered, 
freely  movable,  and  painless.  The  scar  should  not  be  adherent  to 
the  bone,  or  on  that  portion  of  the  stump  which  is  subjected  to 
pressure,  e.g.,  on  the  palmar  surface  of  the  hand  or  plantar  surface 
of  the  foot.  The  most  favorable  situation  for  a  scar  after  higher 
amputations  is  mentioned  in  the  paragraph  on  artificial  limbs. 
All  of  the  tissues  of  a  stump  necessarily  atrophy.  The  end  of  the 
bone  becomes  smooth,  and  the  medullary  cavity  is  often  closed  by 
osseous  tissue. 

Necrosis  of  the  end  of  the  bone  may  be  caused  by  stripping  up  of 
the  periosteum,  especially  when  followed  by  infection.  Diffuse 
septic  osteomyelitis  and  secondary  hemorrhage  are  unusual  complica- 
tions in  civil  practice.  Sloughing  of  the  flaps  results  from  amputating 
too  close  to  the  lesion,  too  thin  flaps,  arterial  disease  (atheroma), 
infection,  or  from  some  debilitating  constitutional  malady,  espe- 
cially diabetes.  If  extensive,  reamputation  may  be  needed.  Conical 
stump  is  caused  by  too  short  flaps,  cicatricial  contraction  following 
septic  processes,  and,  in  the  young,  from  continued  growth  of  the 
bone  (Fig.  565).     In  the  worst  cases  the  end  of  the  bone  is  exposed. 


EXTREMITIES 


1007 


The  treatment  is  reamputation.  Painful  stump,  apart  from  ulcera- 
tion (vide  infra),  is  caused  by  disease  of  the  bone  or  the  nerves. 
Periostitis,  ostitis,  and  exostoses,  formerly  thought  to  be  of  secondary 
importance,  have,  since  the  advent  of  the  X-ray,  been  proved  to  be 
responsible  for  most  sensitive  stumps.  If  relief  is  not  obtained  by 
the  ordinary  treatment  for  inflammatory  disease  of  bone,  reamputation, 
according  to  Bunge,  by  the  aperiosteal  method,  should  be  performed. 
Neuralgia  of  a  stump  is  due  to  incarceration  of  a  nerve  in  the  cicatrix, 
to  adhesions  about  a  nerve  at  a  higher  level,  or  to  the  formation  of  a 
neuroma.  A  cicatrix  or  a  neuroma  may  be  excised,  adhesions  sep- 
arated, the  nerve  cut  at  a  higher  level,  or  re- 
amputation performed.  Recurrence  may  be 
prevented  as  already  indicated  in  the  para- 
graph on  "Division  of  the  Tissues."  Spas- 
modic stump  may  complicate  neuralgia,  and 
is  then  curable  by  the  same  treatment.  When 
of  central  origin,  relief  is  usually  not  obtained. 
Ulceration  of  the  scar  is  prone  to  develop  if 
it  is  thin  and  adherent  or  exposed  to  pressure, 
although  it  may  depend  upon  some  constitu- 
tional disease,  notably  syphilis.  The  worst 
cases  require  reamputation.  Occasionally 
epithelioma  develops. 

Artificial  limbs  are  adjusted  after  the 
stump  has  shrunken  and  become  soHd  and 
resistant.  In  order  to  hasten  this  process  the 
stump  should,  as  soon  as  the  wound  is  healed, 
be  bandaged  firmly,  or  a  leather  "stump 
corset"  worn,  after  several  weeks  of  which 
treatment  measurements  can  be  made  for  the 
new  limb.     While  waiting  for  the  new  limb 

massage  and  active  motions  should  be  practised,  in  order  to  maintain 
the  nutrition  of  the  part,  and  prevent  fixation  of  the  neighboring 
joint  at  an  inconvenient  angle.  Slight  shrinkage  of  the  stump  after 
the  limb  is  applied  can  be  compensated  by  wearing  a  thicker  stock- 
ing; marked  shrinkage  will  necessitate  a  new  socket.  As  the  end 
of  a  stump  in  the  upper  extremity,  exclusive  of  the  hand,  is  not 
subjected  to  pressure,  even  by  an  artificial  arm,  which  is  hollow 
and  takes  its  support  from  the  sides  of  the  limb,  the  best  place 
for  the  cicatrix  is  on  the  face  of  the  stump.  In  the  lower  ex- 
tremity, if  the  patient  is  to  wear  a  modern  artificial  leg.  which  is 
constructed  in  the  same  manner  as  an  artificial  arm   the  most  favor- 


FiG.  565. — Conical  stump 
from  continued  growth  of 
bone.     Reamputation. 


looS 


MANUAL   OF   SURGERY 


able  site  for  the  scar  is  on  the  end  of  the  stump.  If  the  patient  is  to 
wear  a  "poor  man's  leg,"  i.e.  a  solid  one  which  receives" the  weight 
of  the  body  through  the  end  of  the  stump,  the  scar  should,  if  possible, 
be  placed  on  the  side  of  the  stump,  and  the  stump  should,  as  soon  as 
healed,  be  prepared  for  weight  bearing  by  pressing  it,  several  times 
daily,  for  gradually  increasing  periods,  against  a  bran  bag,  and,  later, 
against  a  board,  after  which  practice  with  the  peg-leg  should  be 
started. 

SPECIAL  AMPUTATIONS 

In  many  cases,  particularly  after  injuries,  no  set  amputation 
is  applicable;  one  must  remove  the  devitalized  or  diseased  tissues 


Fig.  566. — Dorsal  surface  of  hand.  Disarticulation  at  second  interphalangeal  joint 
(A)  by  equal  lateral  flaps,  (B)  by  racquet  incision,  (C)  by  short  posterior  and  long  anter- 
ior flap.  Disarticulation  at  first  interphalangeal  joint  (D)  by  circular  incision,  (E)  by 
equal  anterior  and  posterior  flaps,  (F)  by  oval  incision,  (G)  by  single  lateral  flap.  Re- 
moval (H)  of  distal  phalanx  of  thumb  by  single  palmar  flap,  (I)  of  index  and  middle 
fingers  at  carpometacarpal  joints  by  racquet  incision,  (J)  or  ring  finger  at  metacarpo- 
phalangeal joint  by  racquet  incision,  (K)  of  little  finger  by  racquet  incision  with  beveling 
of  metacarpal  bone  for  symmetry  as  indicated  by  dotted  line  across  bone,  (L)  of  thumb 
and  metacarpal  bone  by  racquet  incision,  (M)  of  the  four  fingers  and  their  metacarpal 
bones  by  unequal  flaps.     (N)  Disarticulation  at  wrist  by  oval  incision. 

and  fashion  impromptu  flaps  from  that  which  remains,  hence  the 
following  methods  must  be  regarded  as  suggestive  only. 

In  amputation  of  the  fingers  and  hand  the  principal  objects  to 
be  kept  in  mind  are  usefulness  and  the  avoidance  of  a  palmar  scar; 
symmetry    is  of  secondary   importance.     Disarticulation  of    the 


EXTREMITIES  lOOQ 

distal  phalanx  should  be  i)erfornu'(l,  when  possible,  by  o])ening  the 
joiiU  transversely  on  the  dorsal  aspect,  dividinj^  the  lateral  liga- 
ments, and  cutting  a  long  palmar  flap  from  the  pulp  of  the  finger. 
The  incision  outlining  this  flap  passes  from  the  joint-line  down- 
wards along  the  middle  of  the  side  of  the  flnger,  thus  avoiding  the 
palmar  digital  artery,  which  runs  nearer  the  palmar  surface.  The 
incision  then  curves  across  the  palmar  surface  at  a  distance  below 
the  joint-line  equivalent  to  one  and  one-half  diameters  of  the  finger 
at  the  articulation,  and  passes  upwards  along  the  middle  of  the 
opposite  side  of  the  finger  to  the  joint-line.  There  is  no  theca  over 
the  distal  phalanx.  In  amputating  through  the  lower  half  of  the 
middle  phalanx  the  deep  flexor  will  be  severed,  and  should  be  sutured 
to  the  orifice  of  the  theca,  which  is  closed  at  the  same  time.  In 
amputating  through  the  middle  phalanx  above  this  level  or  through 
the  proximal  phalanx  both  flexors  are  severed,  and  should  be  treated 
in  the  same  way.  Each  bone  of  the  thumb,  however,  is  supplied 
with  different  tendons.  The  various  methods  of  amputation  are 
shown  in  Fig.  566.  If  in  doubt  as  to  the  necessity  of  amputation  of 
the  fingers,  do  not  amputate;  the  reverse  is  true  of  the  toes.  When 
amputating  through  a  phalanx  the  section  should  be  made,  not 
with  cutting  forceps,  which  are  apt  to  splinter  the  bone,  but  with 
a  Gigli  saw.  In  a  traumatic  amputation  through  a  phalanx,  one 
may,  in  suitable  cases,  cover  the  raw  surface  with  a  Wolf  graft, 
or  a  pedunculated  flap  from  the  abdomen  or  other  part,  instead  of 
sacrificing  more  bone  in  order  to  secure  flaps.  A  lost  finger  has 
been  replaced  by  a  toe,  transplanted  by  the  Italian  method. 

Amputation  at  the  metacarpo -phalangeal  joint  is  best  done 
by  a  racquet  shaped  incision,  which  starts  over  the  knuckle  and  is 
carried  obliquely  around  the  phalanx  at  the  level  of  the  web  of  the 
finger.  The  articulation  is  opened  from  the  dorsal  side.  Lateral 
flaps  taken  from  the  outer  side  may  be  used  in  amputations  of  the 
thumb,  index,  and  little  fingers.  While  removal  of  the  head  of  the 
metacarpal  bone  increases  symmetry  by  allowing  the  adjoining 
fingers  to  fall  together,  it  impairs  the  strength  of  the  hand,  hence  is 
contraindicated  in  a  laboring  man.  The  metacarpal  bone  can  be 
removed  by  extending  the  incision  corresponding  to  the  handle 
of  the  racquet  upwards. 

Amputation  at  the  wrist  joint  should  as  a  rule,  be  avoided;  it 
gives  too  long  a  stump  for  the  proper  application  of  an  artificial 
hand.  When  necessary  the  amputation  may  be  performed  by  an 
elliptical  incision  (Fig.  566),  which  is  one-half  inch  below  the  arti- 
culation on  the  dorsal  side,  and  two  inches  lower  on  the  palmar  side; 

64 


lOIO 


MANUAL   OF    SURGERY 


it  passes  between  the  pisiform  and  the  base  of  the  fifth  metacarpal 
on  the  ulnar,  and  crosses  the  carpometacarpal  joint  on  the  radial 
side.  The  joint  is  opened  from  the  dorsal  surface.  An  external 
lateral  flap  (Dubreuil's  method)  may  be  made  by  an  incision  which 
starts  on  the  dorsal  surface  at  the  junction  of  the  middle  and  outer 
third  of  the  wrist,  curves  downward  to  the  head  of  the  metacarpal 
bone  of  the  thumb,  and  then  passes  upward  on  the  palmar  surface 
to  a  point  immediately  opposite  its  commencement.     Some  of  the 


m.z/ 


77Z.7Z 


u.a 


.i.a 


p.L.n. 


p.  I. (7. 


Fig.  567. — Section  through  the  forearm  above  the  middle.  (After  Braune,  and 
Esmarch  and  Kowalzig.)  r,  Radius,  ii.  lUlna.  i.m.  Interosseous  membrane.  Mus- 
cles: s.l.  Supinator  longus.  p.r.i.  Pronator  radii  teres,  e.c.r.l.  Extensor  carpi  radialis 
longior.  e.c.r.b.  Extensor  carpi  radialis  brevior.  e.c.d.  Extensor  communis  digitorum. 
e.o.m.p.  Extensor  ossis  metacarpi  pollicis.  e.m.d.  Extensor  minimi  digiti.  e.c.u.  Ex- 
tensor carpi  ulnaris.  f.l.p.  Flexor  longus  pollicis.  f.p.d.  Flexor  profundus  digitorum. 
f.s.d.  Flexor  sublimis  digitorum.  f.c.u.  Flexor  carpi  ulnaris.  p.l.  Palmaris  longus. 
f.c.r.  Flexor  carpi  radialis.  Vessels:  r.a.  Radial  artery  and  venae  comites.  u.a.  Ulnar 
artery,  m.a.  Median  artery,  a.i.a.  Anterior  interosseous  artery,  p.i.a.  Posterior 
interosseous  artery,  s.r.v.  Superficial  radial  vein.  m.v.  Median  vein.  Nerves: 
tn.n.  Median  nerve,  u.n.  Ulnar  nerve,  a.i.n.  Anterior  interosseous  nerve,  p.i.n. 
Posterior  interosseous  nerve,     r.ti.  Radial  nerve.      (Walsham.) 

muscular  tissue  of  the  thenar  eminence  should  be  included  in  the 
flap.  The  ends  of  the  flap  are  connected  by  a  circular  incision  on 
the  ulnar  side  and  the  wrist  disarticulated.  A  long  palmar  flap 
reaching  to  the  middle  of  the  metacarpal  bones  may  be  similarly 
employed. 

Amputation  through  the  forearm  (Figs.  564,  567)  is  best  per- 
formed at  the  junction  of  the  lower  and  middle  thirds;  this  gives 
a  strong  stump,  which  can  be  pronated  and  supinated  and  is  not 


EXTREMITIES 


lOII 


too  long  for  the  adjustment  of  an  artificial  hand.  A  stump  shorter 
than  four  inches,  measuring  from  the  tip  of  the  olecranon,  is  not 
well  suited  for  the  application  of  an  artificial  forearm.  If  not  more 
than  two  inches  of  the  ulna  can  be  left,  it  is  better,  according  to 
Hull,  to  amputate  above  the  condyles  of  the  humerus.  The  fore- 
arm may  be  removed  by  any  of  the  flap  methods.  The  muscles 
should  be  divided  circularly,  the  interosseous  membrane  severed, 
a  three-tailed  muslin  retractor  applied,  and  both  bones  sawed 
through  at  the  same  time,  after  making  a  guiding  groove  in  the 
radius. 

m.cT/  ^-^-^  7n.b.u. 

o.a 


fc.r 


Fig.  568. — Section  through  the  elbow  joint.  (After  Braune,  and  Esmarch  and 
Kowalzig.)  Bones,  ligaments,  and  synovial  membrane:  h.  Humerus,  ex.  External  and 
internal  condyle,  o.  Olecranon,  ej.,  ej.  Elbow  joint,  o.b.  Olecranon  bursa.  e.l.L, 
i.l.l.  External  and  internal  lateral  ligament.  Muscles:  s.l.  Supinator  longus.  e.c.r.  Ex- 
tensor carpi  radialis.  a.n.  Anconeus,  t.  Triceps,  f.c.r.  Flexor  carpi  radialis.  p.r.t. 
Pronator  radii  teres,  b.a.  Brachialis  anticus.  b.  Biceps.  Vessels;  b.  a.  Brachial  artery 
with  venae  comites.  i.p.a.  Inferior  profunda  artery,  m.c.v.  Median  cephalic  vein. 
m.b.v.  Median  basilic  vein,  a.u.v.  Anterior  ulnar  vein,  p.u.v.  Posterior  ulnar  vein. 
Nerves:  m.7t.  Median  nerve,  u.n.  Ulnar  nerve,  r.n.  Radial  nerve,  p.i.n.  Posterior 
interosseous  nerve,  m.b.m.s.n.  Muscular  branch  of  the  musculo-spiral  nerve,  i.c.n. 
Internal  cutaneous  nerve.      (Walsham.) 

Cinematic  amputation  (Vanghetti's  operation)  has  been  employed 
in  the  forearm.  The  tendons  are  cut  longer  than  the  bones,  and 
loops  formed  by  suturing  the  ends  together  or  by  turning  the  tendons 
back  upon  themselves,  or  knobs  made  by  tying  the  ends  in  knots 
or  by  chiseling  oft'  the  bony  insertion.  The  loops  or  knobs  are 
enveloped  in  skin  flaps,  so  that  after  healing  takes  place  they  may 
be  attached  to  hooks  or  strings  and  thus  convey  movement  to  an 
artificial  limb. 


IOI2 


MANUAL   OF   SURGERY 


Disarticulation  at  the  elbow  joint  (Fig.  568)  is  unsatisfactory, 
amputation  above  or  below  the  joint  being  preferable.  When 
undertaken,  the  elliptical  or  long  anterior  flap  method  should  be  used. 

Amputation  through  the  arm  (Figs.  569, 570)  may  be  accomphsh- 
ed  by  any  of  the  methods  as  indicated  by  the  conditions.  The 
stump  should,  if  possible,  be  not  less  than  four  inches  in   length. 

Amputation  at  the  shoulder  joint  may  be  performed  while  the 
subclavian  vessels  are  controlled  by  direct  pressure,  or  the  axillary 
vessels  may  be  ligated  as  a  preliminarry  step.     Elastic  constriction 


m.cn 


ab.sp 


Fig.  569. — Section  through  the  arm  below  the  middle.  (After  Braune,  and  Esmarch 
and  Kowalzig.)  Muscles:  6,  Biceps,  ha.  Brachialis  anticus.  le.  External  head  of  triceps. 
ll.  Long  head  of  triceps.  //.  Inner  head  of  triceps.  Vessels:  h.a.  Brachial  artery  with 
vena  comites.  i.p.a.  Inferior  profunda  artery,  s.p.a.  Superior  profunda  artery. 
a.b.s.p.a.  Articular  branch  of  the  superior  profunda  artery,  b.v.  Basilic  vein.  c.v. 
Cephalic  vein.  Nerves:  w.m.  Median  nerve.  /.c.«.  Internal  cutaneous  nerve.  «.«.  Ul- 
nar nerve.  7n.c.n.  Musculo-cutaneous  nerve,  tn.s.n.  Mjisculo-spiral  nerve.  (Wal- 
sham.) 

by  Wyeth's  method  (see  "Amputation  of  Hip")  has  the  objection 
that  hemorrhage  may  occur  when  the  bone  is  removed.  The 
posterior  pin  enters  at  the  middle  of  the  lower  margin  of  the  posterior 
axillary  fold,  and  emerges  just  behind  and  one  inch  within  the 
acromion  process.  The  anterior  pin  is  introduced  at  the  middle 
of  the  lower  margin  of  the  anterior  axillary  fold  and  emerges  one 
inch  to  the  inner  side  of  the  acromion.  The  constricting  band  is 
applied  above  the  pins.  The  classical  operations  are  those  of 
Spence,  Larry,  and  Dupuytren. 


EXTREMITIES 


IOI3 


S pence's  operation  (anterior  racquet,  Fig.  571)  is  begun  by 
making  an  incision  down  to  the  bone,  from  midway  between  the 
coracoid  and  acromion  process,  downwards  and  outwards  for  three 
or  four  inches,  if  desirable  the  joint  may  be  opened  at  once  for 
examination.  The  knife  is  then  carried  downwards  and  inwards 
across  the  axillary  fold  and  around  the  arm  to  the  end  of  the  primary 
incision.     The  skin  is  reflected  for  an  inch  or  more  and  the  muscles 


Fig.  570. — Section  above  the  middle  of  the  arm.  (After  Braune,  and  Esmarch  and 
Kowalzig.)  Muscles:  p.m.  Pectoralis  major,  h.a.  Brachialis  anticus.  d.  Deltoid,  t.e. 
External  head  of  triceps.  <./.  Long  head  of  triceps,  l.d.  Latissimus  dorsi.  /.w.  Teres 
major,  c.b.  Coraco-brachialis.  b.b.  Short  head  of  biceps,  h.l.  Long  head  of  biceps. 
Vessels:  b.a.  Brachial  artery  with  venas  comites.  s.p.a.  Superior  profunda  artery,  b.v. 
Basilic  vein.  c.v.  Cephalic  vein.  Nerves:  m.n.  Median  nerve,  u.n.  Ulnar  nerve. 
m.s.n.  Musculo-spiral  nerve,  i.c.n.  Internal  cutaneous  nerve,  m.c.n.  Musculo-cuta- 
neous  nerves  (Walsham.) 

on  the  inner  aspect  divided  obliquely,  thus  exposing  the  axillary 
vessels,  which  are  ligated  and  di\'ided.  The  soft  parts  on  the 
outer  side  are  separated  from  the  bone,  the  inner  half  of  the  capsule 
and  the  subcapularis  divided,  the  head  of  the  humerus  drawn 
outwards,  the  division  of  the  capsule  completed,  and  the  remaining 
tissues  cut  by  carrying  the  knife  downwards  close  to  the  inner  side 
of  the  bone,  to  avoid  injury  to  the  posterior  trunk  of  the  circumflex 
artery. 


IOI4 


MANUAL   OF   SURGERY 


Larry's  operation  is  an  external  racquet  amputation  (Fig.  572). 
A  six  inch  vertical  incision  is  made  from  the  tip  of  the  acromion 
down  the  outer  side  of  the  arm.  The  oval  incision  begins  at  the 
center  of  the  vertical  and  is  carried  obhquely  around  the  arm.  The 
flaps  are  reflected  from  the  outer  aspect  of  the  joint  and  the  ex- 
tremity removed  as  in  the  Spence  operation. 

Diipuytren's  amputation  consists  of  a  U-shaped  flap  extending 
from  the  coracoid  to  the  root  of  the  acromion,  the  lowest  point 
reaching  to  the  insertion  of  the  deltoid  (Fig.  572).  The  inner 
flap  is  made  by  an  incision  joining  the  ends  of  the  former  and  ex- 
tending two  inches  below  the  axilla.  Disarticulation  is  accomplished 
as  in  other  methods. 


Fig.  571. — A.  Spence's  amputation. 
B.   Interscapulothoracic  amputation. 


Fig.   572. — A.  Larry's  amputation. 
B.   Dupuytren's  amputation. 


Interscapulo -thoracis  amputation  is  the  removal  of  the  entire 
upper  extremity,  arm,  scapula,  and  the  whole  or  a  portion  of  the 
clavicle.  An  incision  is  made  along  the  clavicle  and  the  subclavian 
vessels  hgated,  after  resecting  the  middle  third  of  the  clavicle 
(Berger),  or  the  disarticulating  its  sternal  end  (Le  Conte),  care  being 
taken  not  to  open  the  pleura.  The  anterior  flap  is  outhned  by 
carrying  the  knife  from  the  center  of  the  clavicular  incision  down- 
wards and  outwards  across  the  anterior  axillary  fold  and  backwards 
to  'the  lower  angle  of  the  scapula  (Fig.  571).  The  muscles  are  sev- 
ered, thus  exposing  the  brachial  nerves,  which  are  cut  on  the  level 
with  the  subclavian  vessels.  The  hmb  is  then  carried  across  the  chest, 
and  a  posterior  flap  made  by  joining  the  ends  of  the  two  previous 
incisions.  The  scapular  muscles  are  detached  and  the  whole  extrem- 
ity removed. 

Amputation  of  the  toes,  excepting  the  great  toe,  are  never  made 


EXTREMITIES 


IOI!C 


except  at  tlu'  nu'tatarso-phalan.^t-al  articulation,  the  operation  then 
being  identical  with  that  described  for  the  fingers,  remembering, 
however,  that  the  point  is  the  same  distance  hchinrl.  as  the  tip  of  the 
toe  is  in  front  of  the  web. 

Disarticulation  at  the  tarso -metatarsal  joint  {Lis franc  amputa- 
tion) is  performed  by  making  a  curved  incision  from  the  base  of  the 
first  metatarsal  across  the  dorsum  of  the  foot  to  the  base  of  the 


Fig.   573. — Incisions  for  (i)  Lisfranc's,  (2)  Chopart's,  (3)  Subastragaloid,  (4)  Pirogoff's, 
and  (5)  Byrne's  amputations. 

fifth  (Fig.  573).  The  plantar  flap  curves  convexly  to  the  root  of 
the  toes,  and  includes  all  the  tissues  of  the  foot  to  the  bones.  To 
disarticulate  (Fig.  574),  the  knife  is  passed  behind  the  projecting 
end  of  the  fifth  metatarsal  and  directed  towards  the  base  of  the  great 
toe;  the  fourth  metatarsal  is  separated  by  cutting  toward  the  middle 
of  the  first  metatarsal,  and  the  third  by  cutting  towards  its  base; 


HEY 

SKEY 


'LISFRANC        IbAUDENS 

Fig.   574. — Diagram  of  amputations  of  foot. 

the  knife  then  glides  over  the  second  metatarsal,  and  enters  the  joint 
of  the  first  metatarsal.  The  second  metatarsal  is  separated  by 
incising  its  dorsal  Kgament  transversely  and  then  cutting  upwards 
betw'een  the  first  and  second  ligament  transversely  and  then  cutting 
upwards  between  the  first  and  second  metatarsals.  By  strongly 
depressing  the  foot  any  remaining  attachments  may  be  severed  and 
the  disarticulation  completed.     In  the  Hey  operation  the  difficulty 


ioi6 


MANUAL   OF   SURGERY 


of  disarticulating  the  second  metatarsal  is  overcome  by  sawing 
through  the  projecting  internal  cuneiform.  In  S key's  method  the 
second  metatarsal  is  sawn  through  at  its  base.  Baunden  V  advised 
disarticulating  the  first  metatarsal  and  sawing  through  the  remaining 
ones  at  the  same  level. 

Disarticulation  at  the  Mid -tarsal  Joint  {C  ho  part's  Amputation, 
Figs.  573,  574). — The  long  plantar  incision  begins  on  the  inner 
side  at  the  tubercle  of  the  scaphoid,  curves  forward  to  within  one 
inch  of  the  ends  of  the  metatarsal  bones,  and  terminates  on  the  outer 


e.cu 


e.p.a. 

Pig.  575. — Syme's  amputation,  showing  the  structures]  divided.  /.  Fibula.  I. 
Tibia,  /.a.  Tibialis  anticus  tendon.  <r.i./z.  Extensor  longushallucis.  a. /.a.  Anterior  tibial 
artery,  a.t.v.  Anterior  tibial  vein,  e.c.d.  Extensor  communis  digitorum.  pn.l.  Pero- 
neus  longus.  pn.  b.  Peroneus  brevis.  f.l.h.  Flexor  longus  hallucis.  I.  Ach.  Tendo 
Achillis,  beneath  which  is  a  bolster  of  fat.  t.p.  Tibialis  posticus,  f.l.d.  Flexor  longus 
digitorum.  p.t.a.  Posterior  tibial  artery  dividing  into  e.p.a.  and  i.p.a.  external  and  in- 
ternal plantar  artery,  e.c.a.  and  i.e. a.  External  and  internal  calcaneal  branches  forming 
the  blood  supply  of  the  thick  heel-flap.      (Walsham.) 


side  at  a  point  midway  between  the  malleolus  and  base  of  the  fifth 
metatarsal.  The  dorsal  incision  curves  slightly  forward  and  unites 
the  ends  of  the  plantar.  The  astragalo-scaphoid  and  the  calcaneo- 
cuboid articulations  are  opened  from  the  dorsal  side.  The  muscles 
and  tendons  of  the  flaps  should  be  sutured  together  taking  particular 
care  to  secure  the  extensor  tendons  and  the  tibialis  anticus,  in  order 
to  oppose  the  tendency  towards  retraction  of  the  heel  by  the  calf 
muscles.  Despite  this  precaution,  however,  the  os  calcis  is  often 
drawn  upwards  subsequently  because  of  the  removal  of  the  anterior 
part  of  the  arch  of  the  foot,  which  leaves  the  posterior  without  any 


EXTREMITIES  lOiy 

support.  As  a  result  the  limb  is  lengthened,  and  the  patient  walks 
on  the  astragalus,  thereby  causing  considerable  pain  and  perhaps 
ulceration.  Forbes  separated  the  cuneiform  bones  from  the  scap- 
hoid and  sawed  through  the  cuboid. 

Subastragaloid  amputation  of  the  foot  makes  a  useful  stump 
covered  by  the  skin  of  the  heel.  A  racquet-shaped  incision  (Fig. 5 73) 
is  made,  commencing  at  the  insertion  of  the  tendon  of  AchilHs,  and 
extending  along  the  outer  side  of  the  foot  to  a  point  just  above  the 
base  of  the  fifth  metatarsal,  where  it  encircles  the  foot.  The  dorsal 
flap  is  reflected,  the  tendon  of  AchilUs  divided,  the  astragalo- 
scaphoid  joint  opened,  the  foot  twisted  inwards,  and  the  astragalus 
separated  from  the  os  calcis,  which  is  then  cleared  and  the  foot 
removed. 

Amputation  at  the  ankle  joint  by  Syme's  or  Pirogoff's  method 
gives  a  clumsy  stump,  but  one  which  is  covered  by  the  resistant  tissues 
of  the  heel  and  capable  of  weight-bearing.  Syme's  amputation 
(Figs.  573.  574,  575)  is  a  disarticulation  at  the  ankle  joint,  with 
removal  of  the  malleoli,  and  a  layer  of  the  articular  surface  of  the  tibia, 
one-fourth  of  an  inch  in  thickness.  An  incision  is  made  down  to  the 
bone  at  the  tip  of  the  external  malleolus,  and  is  carried  under  the 
heel  to  a  point  one-half  inch  below  and  behind  the  inner  malleolus. 
This  flap  is  dissected  from  the  os  calcis,  keeping  close  to  the  bone  to 
avoid  the  calcaneal  vessels.  The  dorsal  incision  unites  the  ends 
of  the  first  and  is  shghtly  convex  downward.  The  ankle  joint  is 
then  opened  from  the  dorsal  aspect,  the  posterior  ligaments  and  the 
tendon  of  Achillis  divided,  and  the  lower  ends  of  the  tibia  and  fibula 
removed  with  the  saw. 

Pirogoff's  amputation  differs  from  Syme's  in  that  the  posterior 
portion  of  the  os  calcis  is  sawn  off  and  approximated  to  the  sawn 
ends  of  the  tibia  and  fibula,  the  plantar  incision,  forming  a  right 
angle  with  the  dorsal,  being  carried  obliquely  forward  instead  of 
vertically  downwards  (Fig.  573).  The  lower  ends  of  the  tibia  and 
fibula  are  sawn  obHquely  and  almost  parallel  with  the  sawn  surface 
of  the  OS  calcis  (Fig.  574).  The  bones  are  then  approximated  and 
held  in  place  by  wire,  or  by  catgut  sutures  passing  through  the  per- 
iosteum. LeFort  modifies  this  operation  by  sawing  the  tibia  and 
OS  calcis  horizontally.  Ferguson  allowed  the  malleoli  to  remain  and 
brought  the  fragment  of  the  os  calcis  up  between  the  two. 

Amputation  through  the  leg  should  never  be  performed  within 
three  inches  of  the  upper  end  of  the  tibia,  as  the  stump  is  too  short 
to  provide  the  leverage  necessary  for  manipulating  an  artificial 
limb,  and  is  apt  to  become  permanently  flexed  as  the  result  of  con- 


ioi8 


MANUAL   OF    SURGERY 


traction  of  the  ham-string  muscles.  Amputation  just  above  the 
ankle,  although  occasionally  performed,  likewise  is  objectionable, 
in  that  the  stump,  which  consists  merely  of  skin,  bone,  and  tendon, 
is  often  badly  nourished,  hence  predisposed  to  ulceration.  The 
point  of  election  for  amputation  through  the  leg,  so  far  as  subsequent 


men 


u.l.n 


pf.n 


Fig.  576. — Section  through  the  lower  third  of  the  leg.  (After  Braune,  Esmarch  and 
Kowalzig.)  /.Fibula.  ^  Tibia.  «.w.  Interosseous  membrane.  Muscles  and  tendons: 
t.a.  Tibialis  anticus.  c.l.h.  Extensor  longus  haUucis.  e.l.d.  Extensor  longus  digitorum. 
pn.l.  Peroneus  longus.  pn.h.  Peroneus  brevis.  t.p.  Tibialis  posticus,  f.l.h.  Flexor 
longus  hallucis.  g.s.  Gastrocnemius  and  soleus  forming  the  tendo  Achillis.  pl.i. 
Plantaris  tendon,  f.l.d.  Flexor  longus  digitorum.  Vessels:  a.t.a.  Anterior  tibial  artery. 
pn.a.  Peroneal  artery,  p.t.a.  Posterior  tibial  artery,  i.s.v.  Internal  saphenous  vein. 
e.s.v.  External  saphenous  vein.  Nerves:  a.i.n.  Anterior  tibial  nerve,  m.c.n.  Musculo- 
cutaneous nerves,  p.t.n.  Posterior  tibial  nerve,  s.s.n.  Short  saphenous  nerve,  l.s.n. 
Long  saphenous  nerve.     (Walsham.) 

prosthesis  is  concerned,  is  at  the  junction  of  the  middle  and  lower 
thirds.  The  fibula  should  always  be  divided  at  a  higher  level  than 
the  tibia,  the  sharp  anterior  edge  of  which  should  be  beveled.  As 
in  the  forearm,  a  three  tailed  retractor  will  be  needed  to  keep  the 


Fig. 


577- 
Teale's  amputation. 


Fig.  578. 


(MouUin.) 


soft  parts  out  of  harm's  way  when  the  saw  is  used.  In  the  lower 
third  (Fig.  576)  lateral  flaps  of  equal  length  are  perhaps  the  best. 
Osteoplastic  flaps  (Moschcowitz)  may  be  obtained  from  the  malleoli 
and  made  to  cover  the  ends  of  the  two  bones;  they  should  be  on  the 
same  plane  as  the  articular  cartilage  of  the  tibia.  Teal's  method 
(Figs.  577,  578)  consists  of  two  rectangular  flaps  including  all  the 


EXTREMITIES 


/ 
IOI9 


Structures  down  to  the  bone.  'J'he  lenf^^th  and  breadth  of  the  long 
flap,  which  is  taken  from  the  surface  where  the  bone  is  most  super- 
ficial, should  be  equal  to  one  half  the  circumference  of  the  leg  at 
the  proposed  site  of  anipulalion.  The  short  flap,  containing  the 
main  blood  bessels,  is  one-([uater  the  length  of  the  long  flap.  In  the 
middle  and  upper  thirds  likewise  (Fig.  579),  two  lateral  flaps  of 
equal  length  are  satisf actor}',  or  the  external  flap  may  be  long  and 
the  internal  short.  In  the  latter  operation  care  should  be  taken 
to  cut  the  anterior  tibial  artery  long,  and  not  to  injure  it  in  separating 


/.m. 


pn.n 


-p.l.a 
p.ln 


if-k-p/.i 


■s.s.n 


e.  s.  f/ 

Fig.  579. — Section  through  the  middle  ot  the  leg.  (After  Braune,  and  Esniarch  and 
Kowalzig.)  /.  Fibula,  t.  Tibia,  i.m.  Interosseous  membrane.  Muscles:  t.a.  Tibialis 
anticus.  e.l.d.  Extensor  longus  digitorum.  p.l.  Peroneus  longus.  t.p.  Tibialis  posticus. 
s.  Soleus.  g.g.  Gastrocnemius,  pi.  t.  Plantaris.  Vessels:  a.t.a.  Anterior  tibial  artery 
with  venae  comites.  p. t.a.  Posterior  tibial  artery,  pn.a.  Peroneal  artery,  i.s.v., 
e.s.v.  Internal  and  external  saphenous  vein.  Nerves:  a.t.n.  Anterior  tibial  nerve. 
pn.  n.  Peroneal  nerve,  p.l.n.  Posterior  tibial  nerve,  l.s.n.  Long  saphenous  nerve. 
s.s.n.  Short  saphenous  nerve.     (Walsham.) 

the  interosseous  membrane.  An  oblong  osteoplastic  flap  (Bier)  may 
be  sa^^^l  from  the  anterior  portion  of  the  tibia,  and  turned  upward 
by  fracturing  its  upper  border;  the  periosteum  forming  the  hinge 
of  the  flap  is  then  separated  from  the  tibia  for  a  short  distance,  the 
tibia  and  fibula  divided  on  a  level  with  the  base  of  the  hinge,  and 
the  flap  sutured  over  the  ends  of  the  bones  wdth  chromicized  catgut 
sutures  passing  through  the  periosteum  (Figs.  580,  581).  The 
advantages  claimed  are  the  closure  and  protection  of  the  medullary 
canal,  increased  stability  of  the  bone,  and  a  movable  skin  flap.  Bin- 
nie  simplifies  this  operation  by  using  a  free  transplant  of  bone  cover- 
ed with  periosteum.     Another  method  (Bier) .  which  can  be  employed 


I020 


MANUAL   OF   SURGERY 


in  any  region,  is  to  remove  a  wedge  of  bone  a  short  distance  above 
the  line  of  amputation,  and  close  the  wedge  at  the  completion  of  the 
operation,  thus  changing  the  position  of  the  scar  and  closing  the 


Fig.  580. 
Bier's  osteoplastic  amputation  of  leg. 


Fig.  581. 
(Esmarch  and  Kowalzig.) 


pa 


e.s.i/ 


Pig.  582. — Section  through  the  condyles  of  the  femur,  to  show  the  relations  of  the 
structures.  (After  Braune,  and  Esmarch  and  Kowalzig.)  /.  Femur,  p.  Patella. 
Muscles:  g.i.,  g.e.  External  and  internal  head  of  the  gastrocnemius.  5.  Sartorius. 
sm.  Semi-membranosus,  gr.  GraciHs.  st.  Semi-tendinosus.  h.  Biceps,  k.j.  Knee 
joint.  *././.,  e.l.l.  Internal  and  external  lateral  ligament,  p.c.l.  Posterior  and  crucial 
ligaments.  Vessels;  po.a.  PopUteal  artery,  ar.a.  Articular  branch,  an.a.  Anastomotic 
artery,  po.v.  Popliteal  vein,  i.s.v.  Internal  saphenous  vein,  e.s.v.  External  saphenous 
vein,  e.s.v.  External  saphenous  vein.  Nerves:  e.po.n.  External  popliteal  nerve. 
i.po.n.  Internal  popUteal  nerve,     l.s.n.  Long  saphenous  nerve.      (Walsham.) 


medullary  ca\dty.  Osteoplastic  amputations  are  tedious,  and  are 
contraindicated  in  the  presence  of  infection,  and  in  most  traumatic 
cases. 


EXTREMITIES 


I02I 


Disarticulation  at  the  knee  joint  (see  Fig.  582  for  relations)  may 
be  effected  alter  making  bilateral  flaps.  Two  semilunar  incisions, 
starting  at  a  point  just  below  the  tibial  tubercle,  curve  around  each 
side  of  the  leg,  meeting  again  posteriorly  in  the  midline  on  a  level 
with  the  joint.  As  the  internal  condyle  is  the  larger,  the  inner  flap 
should  be  longer.  The  ligamentum  patellae  is  divided  and  the  joint 
opened  and  disarticulated.  A  long  anterior  flap  may  be  made  by 
an  incision  from  one  condyle  to  the  other,  and  extending  to  a  point 


Pig.  583. 

Garden's  amputation. 


Fig.  584. 


(MouUin.) 


five  inches  below  the  patella;  a  short  curved  incision  unites  the  ends 
of  the  former.  The  patella  should  be  removed,  or  fastened  between 
the  condyles.  The  stump  is  ungainly  in  appearance  but  capable 
of  bearing  weight. 

Supracondyloid  Amputation  of  the  Femur  (Garden's  Method) . 
An  anterior  semilunar  flap  of  skin  and  subcutaneous  tissues  is  out- 
lined by  an  incision  passing  from  one  condyle  to  the  other,  and  reach- 
ing downward  to  two  inches  below  the  patella;  the  posterior  flap  is 


Fig.  586. 


Gritti's  amputation. 


made  by  an  incision  connecting  the  ends  of  the  anterior  and  passing 
through  all  the  soft  tissues  (Figs.  583,  584).  The  condyles  are 
divided  just  below  the  epiphyseal  line  and  the  sharp  edges  rounded 
with  rongeur  forceps.  Gritti's  osteoplastic  method. — An  anterior 
semilunar  flap  extends  from  the  condyles  of  the  femur  to  the  tibial 
tubercle  and  includes  the  quadriceps  extensor  tendon  and  the  pa- 
tella; the  posterior  is  made  by  an  incision  connecting  the  ends  of 
the  anterior.     The  condyles  of  the  femur  are  divided  just  above  the 


I022 


MANUAL   OF    SURGERY 


articulation.  The  posterior  surface  of  the  patella  is  then  removed 
with  a  fine  saw  and  the  remaining  portion  sutured  to  the  sawn  sur- 
face of  the  femur  with  catgut  passing  through  the  periosteum,  -or 


I-:g.  S87.  Fig. 

Sabanejeff's  amputation. 


d/.a.p 


s.u 

Fig.  589. — Section  of  the  thigh  at  the  junction  of  the  middle  and  lower  third. 
(After  Braune,  and  Esmarch  and  Kowalzig.)  /.  Femur.  Muscles:  v.i.  Vastus  internus. 
r.f.  Rectus  femoris.  cr.  Crureus.  v.e.  Vastus  externus.  h.h.,  b.l..  Short  and  long 
head  of  the  biceps,  si.  Semi-tendinosis.  sin.  Semi-membranosus.  gr.  Gracilis. 
5.  Sartorius.  a.m.  Adductor  magnus,  artery  about  to  pass  through.  Vessels:  s.f.a 
Superficial  femoral  artery,  an.  a.  Anastomotic  artery,  d.f.a.p.  Deep  femoral  artery 
perforating,  s.a.  Sciatic  artery,  s.f.v.  Superficial  femoral  vein,  i.s.v.  Internal  saph- 
enous vein.      Nerves:   s.71.   Sciatic   nerve.     l.s.7i.  Long   saphenous  nerve.      (Walsham.) 

with  wire  (Figs.  585,  586).     Sabatiejef  covers  the  end  of  the  femur 
with  a  bone  flap  from  the  tibia  (Figs.  587,  588). 

Amputation  through  the  thigh  (Fig.  589)  may  be  performed  by 


EXTREMITIES 


1023 


any  of  the  usual  methods,  the  modified  flap  and  circular  being  per- 
haps the  best.  The  most  favorable  site  for  section  of  the  femur  is 
at  the  junction  of  the  middle  and  lower  thirds.  Amputation  close 
to  the  lower  end  gives  a  stump  which  is  too  long  for  a  mechanical 
knee-joint,  amputation  within  live  inches  of  the  crotch  gives  a  stump 
which  is  too  short  for  wielding  a  false  limb. 

Amputation  at  the  hip  joint  (PMg.  590)  is  accompanied  by  unusual 
risks   from   hemorrhage,    shock,   and   sepsis.     Hemorrhage  may  be 


a.c.n6 


d/i. 


Fig.  590. — Section  of  the  upper  third  of  the  thigh  to  show  the  relation  of  the  struc- 
tures divided  in  amputation  of  the  hip.  (After  Braune,  and  Esmarch  and  Kowalzig.) 
/.  Femur.  Muscles:  5.  Sartorius.  r.j-  Rectus  femoris.  i-f-f-  Tensor  fascias  femoris. 
V.  Vastus,  g.tn.  Gluteus  maximus.  st.  Semi-tendinosis.  sm.  Semi-membranosus. 
a.m.  Adductor  magnus.  a.h.  Adductor  brevis.  gr.  Gracilis,  a.l.  Adductor  longus. 
Vessels:  s.j.a.  Superficial  femoral  artery,  d.j.a.  Deep  femoral  artery,  d.f.p.a.  Deep 
femoral  perforating  artery,  g.a.  Gluteal  artery,  s.a.  Sciatic  artery,  s.f.v.  Superficial 
femoral  vein,  d.f.v.  Deep  femoral  vein,  i.s.v.  Internal  saphenous  vein.  Nerves: 
a.c.n.b.  Anterior  crural  nerve  branches,  s.n.  Sciatic  nerve,  s.o.n.  Superficial  obturat 
nerve,     d.o.n.  Deep  obturator  nerve.      (Walsham.) 


controlled  by  (i)  preliminary  exposure  and  ligation  of  the  femoral 
vessels,  with  subsequent  clamping  of  the  smaller  ones  as  they  are 
divided  (the  best  method) ;  (2)  pressure  upon  the  aorta  by  various 
forms  of  tourniquets  (dangerous) ;  (3)  pressure  upon  the  external 
iliac  vessels  wath  Davy's  rectal  lever  (dangerous) ;  (4)  direct  digital 
pressure  on  these  vessels  through  an  abdominal  incision  (McBurney) 
or  (5)  by  a  rubber  tourniquet  held  close  to  the  brim  of  the  pelvis  by 
two  long  steel  pins  (Wyeth) ,  by  sutures,  or  by  a  loop  passing  around 
the    abdomen.     In    Wyeth's    bloodless    method,    "after    exsangui- 


I024  MANUAL   OF   SURGERY 

nating  the  limb  one  pin  is  introduced  one-fourth  of  an  inch  below 
and  within  the  anterior  superior  spine  of  the  ilium,  and  after  tra- 
versing the  muscles  and  fascia  on  the  outer  side  of  the  hip,  emerges 
on  a  level  with  the  point  of  entrance.  The  point  of  the  second  pin 
is  thrust  through  the  skin  and  tendon  of  the  origin  of  the  adductor 
longus  muscle  one-half  inch  below  the  crotch,  the  point  emerging 
one  inch  below  the  tuber  ischii.  The  points  should  be  shielded  at 
once  with  corks  to  prevent  injury  to  the  hands  of  the  operator.  No 
vessels  are  endangered  by  these  skewers.  A  piece  of  strong 
rubber  tubing,  one-half  inch  in  diameter  when  unstretched,  and  long 
enough  when  in  position  to  go  five  or  six  times  around  the  thigh,  is 
now  wound  tightly  around  above  the  fixation  needles."  The  thigh 
is  amputated  by  an  external  racquet  incision,  the  external  portion 
of  which  extends  from  the  rubber  band  downwards  for  six  inches 
then  being  completed  by  a  circular  incision  around  the  thigh.  The 
skin  and  subcutaneous  tissues  are  reflected  to  the  lesser  trochanter 
and  the  muscles  cut  at  this  level.  The  capsule  of  the  joint  is  opened 
and  the  thigh  carried  upward,  inward,  and  forward,  thus  forcing  the 
head  of  the  bone  from  the  socket.  The  round  ligament  is  then 
severed  and  the  limb  removed.  Senn  perforates  the  thigh  close  to 
the  head  of  the  femur  with  a  double  rubber  tube,  one-half  of  which  is 
tied  in  front  and  the  other  half  behind.  Esmarch  divides  the  femur 
at  the  level  of  the  circular  incision,  ties  all  blood  vessels,  removes  the 
constrictor,  and  then  enucleates  the  upper  end  of  the  femur.  Per- 
haps the  best  method,  when  applicable,  is  the  anterior  racquet  am- 
putation without  the  use  of  a  constrictor.  A  longitudinal  incision  is 
made  from  the  middle  of  Poupart's  ligament  downwards  for  three 
inches.  The  common  femoral  vessels  are  divided  between  ligatures, 
and  the  incision  continued  downwards  and  inwards  across  the  inner 
side  of  the  thigh  about  four  inches  below  the  crotch,  thence  continu- 
ing around  the  thigh  to  join  the  primary  incision.  The  outer  flap, 
including  the  muscles,  is  separated  from  the  femur,  any  bleeding 
vessels  being  caught  and  tied  as  they  are  encountered.  The  limb 
is  then  rotated  outwards  and  the  process  repeated  on  the  inner  side. 
The  capsule  is  now  opened,  the  head  of  the  bone  disarticulated  for- 
ward, the  ligamentum  teres  divided,  and  the  tissues  on  the  posterior 
surface  severed  by  carrying  the  knife  downwards  and  outwards 
behind  the  bone. 

Interilio -abdominal  amputation,  in  which  the  entire  lower 
extremity,  including  the  whole  or  a  portion  of  the  innominate  bone, 
is  removed,  has  been  performed  thirty-four  times  w^ith  ten  recov- 
eries (Ransohoff). 


INDEX 


Abbe's  string  saw,  for  esophageal  stric- 
ture, 662 
operation  on  the  fifth  nerve,  352 
Abbott's  treatment  of  scoliosis,  556 
Abdomen,  afifections  of,  665 
contusions,  670 
phantom  tumor  of,  677 
wounds  of,  670 
Abdominal  aorta,  compression  of,  313 
ligation  of,  329 
apertures,  745 
hemorrhage,  666 
hernia,  799 
hydrocele,  911 
hysterectomy,  949,  954 
infection,  666 
myomectomy,  950 
operations,  general  remarks  on,  666 
postoperative  measures,  72 
pregnancy,  961 
section,  666 
surgery,  666 
tonsil,  765 

tumor,  see  special  organs 
vessels,  rupture  of,  670 
viscera,  effects  of  injury,  670 
walls,  injuries  of,  668 
hematoma,  670 
muscular  rupture,  670 
suppuration,  670 
wounds,  675 

nonpenetrating,  675 
penetrating,  675 
Abducens  nerve,  353 
Abrasion,  139 
Abscess,  108 
acute,  no 

diagnosis  of,  no 
symptoms  of,  no 
treatment,  no,  in 
varieties  of,  109 

see  also  special  regions 
chronic,  112 

diagnosis  of,  114 
symptoms  of,  112 
treatment,  114 

see  also  special  regions 
tuberculous,  see  chronic 

65 


Absorption,  97 

Absorptive  power  of  stomach,  testing,  702 

Accessory  auricles,  566 

thyroids,  576 
A.  C.  E.  anesthetic  mixture,  31 
Acetabulum,  fracture  of,  411 
Acetanilid,  55 
Acetonemia,  36 
Acetonuria,  36,  35 
Achillodynia,  998 
Achondroplasia,  442 
Achorion  Schonleinii,  51 
Acid  burns,  159 
Acinous  adenoma,  216 

carcinoma,  218 
Acne,  Rontgen  rays  in  treatment  of,  iS 

sj-philitic,  197 
Acquired  dermoids,  233 

dislocation,  453 

diverticula,  657 
esophageal,  657 

inguinal  hernia,  802 

s\-philis,  191 

valgus,  994 
Acriflavine,  55 
Acromegaly,  443 

Acromial  end  of  clavicle,  dislocation,  458 
Acromion,  process  of  scapula,  395 

fracture  of,  395 
Actinomjxes,  188 
Actinomycosis,  188,  51 
Acupressure,  313 
Acupuncture  for  aneurysm,  301 

neuritis,  342 
Acute  cancer,  218 
Adams'  osteotomy,  493 
Address,  in  diagnosis,  2 
Adenitis,  cervical,  338 

femoral,  338 

inguinal,  338 
Adenoids,  595 
Adenoma,  216 

see  also  special  regions 
Adenocarcinoma,  216 
Adenomatous  goiter,  579 
Adenomyxoma,  216 
Adenosarcoma,  216 

of  breast,  625 


I026 


INDEX 


Adhesions,  intestinal,  744 
Adhesive  inflammation,  93 

plaster,  sterilized,  140 
Adrenalin  chlorid,  38,  310 
Adult  tumor,  214 
Adventitious  bursas,  372 
Adynamic  ileus,  752 

inflammation,  93 
Aerial  fistula,  125 
Aerobes,  43 

aerogenic  bacteria,  263 
Age,  in  diagnosis,  2 
Agglutination,  14,  48 
Agglutinins,  48 
Agnew's  splint,  422 
Agonal  leukocytosis,  12 
Agraphia,  506 
Ainhum,  130 
Air  embolism,  270 

hunger,  307 

in  subcutaneous  emphysema,  263 
Air-passages,  foreign  bodies  in,  599 

operations  upon,  605 
Albee's  operation  for  spinal  tuberculosis, 

449 
Albert's  disease,  998 
Albuminoid  degeneration,  113 

disease,  113 
Albuminuria,  203 
Alcohol,  54 
Alcoholism,  514 
Aleppo  boil,  247 
Alexander's  operation  of  shortening  the 

round  ligaments,  942 
Alexia,  506 
Alexins,  48 
Alkali  burns,  159 
Allis'  inhaler,  24 

method  of  reduction  of  dislocation  of 
hip  joint,  468,  466,  469 
Alopecia  in  syphilis,  198 
.  Aluminium  bronze  wire,  62 
Alveolar  processes,  affections  of,  648 

abscess,  648 

sarcoma,  229 
Amazia,  620 

Ambulant  erysipelas,  175 
Ambulatory  treatment  of  fractures,  381 
Ameba  coli,  51,  107 
Amenorrhea,  954 
Amnesic  aphasia,  506 
Amputation  stump,  1006 

affections  of,  1006 
Amputations,  999 

aperiosteal,  1000 


Amputations,  divisions  of  tissues,  1002 

flapless,  1006 

indications,  1000 

permanent    control    of    hemorrhage, 
1003 

preliminary   control  of   hemorrhage, 
1001 

types  of,  1003 

see  also  special  regions 
Amyloid  disease,  113 
Anaerobes,  43 
Anal,  see  anus 
Anaphylaxis,  50 
Anastomosis,  arterial,  317 

aneurysm  by,  294 

intestinal,  end  to  end,  760 
lateral,  763 

neural,  348 

ureteral,  865 
Anatomical  tubercle,  250 
Anel's  operation  for  aneurysm,  302 
Anemia,  12 

infantum,  798 
Anemic  infarct,  268 
Anesthesia,  21 

after  effects,  35 

Bier's  intravenous,  39,  40 

circulatory  difficulties  in,  34 

complications  during,  32 

contraindicationSj  21 

death  rate,  21 

following  nerve  rupture,  345 

general,  21 

Mikulicz's  law,  12 

indications  for,  21 

infiltration,  38 

Kummel's,  28 

local,  37 

indications  for,  37 
technic  for,  39 

massage  of  heart  in  collapse  during, 
274 

parasacrol,  39 

paravertebral,  39 

posture  in  23 

preparation  of  anesthetist,  23 
patient,  22,  23 

primary,  25 

Ransohoff's  arterial  anesthesia,  40 

recovery  from,  34,  27 

rectal,  28 

respiratory  difficulties,  32 

scopolamin-morphin,  31 

spinal,  40 

stages  of,  25 


INDEX 


1027 


Anesthetics,  21 

administration  of,  24 

adrenalin  chlorid,  38 

atropin,  31 

Barker's  solution,  38 

carbolic  acid,  53 

chloroform,  21 

choice  of,  21 

cocain  hydrochlorid,  37 

contraindications  for,  37 

ether,  21 

ethyl  bromid,  31 

chlorid,  30 
eucain  hydrochlorid,  37 
ice  and  salt,  37 
inhalers  for  administration  of 
Allis,  24 
Clover,  24 
Esmarch,  28 
Skinner,  28 
intraneural  injection,  39 
liquid  air,  37 
methj'l  chlorid,  37 
mixtures,  31 
nitrous  oxid,  29,  30,  21 
novocain,  38 
paraneural  injections,  39 
Quinin-urea  hydrochlorid,  38 
Schleich's  solution,  38 
scopolamin-morphin,  31 
stovain,  38 
tropacocain,  38 
Aneurysm,  291,  294,  226 
cirsoid,  294 
diagnosis,  298 
duration,  298 
etiology,  296 
fusiform,  296 
gangrene  of,  298 
inflammation,  298 
parts  of,  295 
rupture,  298 
sacculated,  296 
symptoms,  297 
treatment,  300 
medical,  300 
surgical,  300 

amputation,  304 

compression,  300 

end  to  end  arterial  anastomosis, 
304,  226 

extirpation,  304 

incision,  303 

introduction    of    foreign    bodies 
into  sac,  301 


Aneurysm,   treatment,   surgical,  ligation, 
302 
venous  transplantation,  304 

tubulated,  296 
Aneurysm  by  anastomosis,  294 
Aneurysmal   varix,  305,  304 
Angina  Ludovici,  575 
Angioma,  226 

telangiectaticum,  226 
Angiorrhaphy,  315 
Angiosarcoma,  231 
Angiosclerosis,  290 
Angiotribe,  314 
Angle's  bands,  389 
Angular  curvature  of  spine,  557 

convolution,  504 
Animal  bites,  182 

tuberculosis,  208 
Ankle  joint,  amputation  at,  1017 

disease,  486 

dislocation  of,  471 

effusion  into,  476 

excision  of,  498,  487 

fracture-dislocation  of,  427 
Ankyloglossia,  643 
Ankylosis,  491,  492 
Anociassociation,  31 
Anodyne  for  sepsis,  172 
Anorchism,  902 
Anosmia,  349 
Anteflexion  of  uterus,  938 
Anterior  crural  nerve,  injury  of,  360 

gastroenterostomy,  711 

poliomyelitis,  564 

tibial  artery,  compression  of,  313 
ligation  of,  334 
Anteversion  of  uterus,  938 
Antevesical  hernia,  805 
Anthrax,  185,  187,  186 
Antibacterial  serums,  171 
Antibiosis,  46 
Antigens,  48 

Antigonococcus  serum,  480 
Antiphthisin,  213 
Antipyretic  for  sepsis,  172 
Antirabies  vaccination,  184 
Antisepsis,  51 
Antiseptic  operation,  68 
Antiseptics,  56,  51 
Antistaphylococcic  serum,  49 
Antistreptococcic  serum,    171 
Antitetanic  serum,  49,  181 
Antitoxins,  48,  181 
Antivenene,  154 
Antrum  of  Highmore,  affections  of,  597 


I028 


INDEX 


Antyllus's  operation  for  aneurysm,  303 
Anuria,  847 

calculous,  857 

non-obstructive,  847 

obstructive,  847,  667 

reflex,  857,  847 
Anus,  abscess  of,  830 

absence  of,  827 

artificial,  754 

condyloma  of,  198 

epithelioma  of,  839,  217 

fissure  of,  829 

fistula  of,  832 

complete  or  true,  833 
blind  external,  832 
internal,  833 

imperforate,  826 

prolapse  of,  837 

pruritus  of,  829 

stricture  of,  826 

tumors,  839 
Aorta,  aneurysm  of,  301,  296 

compression  of,  301 

ligature  of,  329 
Apertures,  abdominal,  745 
Aphasia,  506 
Aphonia,  275,  576 
Aphthous  stomatitis,  647 
Apnea,  610 

in  anesthesia,  26 
Apoplexy,  515,  5 19 

in  anesthesia,  36 
Appendages,  245 
Appendectomy,  770 
Appendiceal  abscess,  772 
Appendicitis,  765 

abscess  in,  767 

causes  of,  766 

complications  of,  767 

diagnosis  of,  769 

operation  for,  770 
sequelae  to,  773 

pathology  of,  766 

symptoms  of,  767 

treatment  of,  770 

varieties  of,  766 
Appendicostomy,  773 
Appendicular  dyspepsia,  693 
Appendix  vermiformis,  in  hernial  sac,  801 

use  of,  in  treatment  of  colitis,  773 
Apraxia,  506 
Ardor  urinae,  885 
Areolar  abscess,  621 
Arm,  amputation  through,  1012 
chancre  of,  193 


Arm,  position  in  operations,  68 
Arsenical  neuritis,  342 
Arsphenamin,  203 
Arterial  anastomosis,  317 

aneurysm,  293 

hemorrhage,  306 
control  of,  308 

stupor,  292 

suture,  314 

thrombosis,  290,  266,  131 

varix,  294 
Arteries,  digital  compression  of,  301,  311 

diseases  of,  290 

injuries  of,  292,  293 

ligation  of,  314 

gangrene  following,  131 

wounds  of,  293,  294 
Arteriocapillary  fibrosis,  290 
Arteriomesenteric  occlusion,  700 
Arteriorrhaphy,  316 

Carrel's  method,  316 
Arteriosclerosis,  290,  291,  21,  280 
Arteriovenous  aneurysm,  305,  304,  293 

wounds,  305 
Arteritis,  290 

acute,  290 

chronic,  290 

syphilitic,  291 
Arthrectomy,  495,  482 
Arthritis,  acute,  478 

chronic,  479 

deformans,  488 

gonorrheal,  479 

gouty,  487 

gummatous,  480 

infantile,  432 

neuropathic,  489 

panarthritis,  478 

pneumococcal,  479 

pyemic,  478 

rheumatic,  487 

rheumatoid,  488 

simple,  478 

suppurative,  478 

syphilitic,  480 

tuberculous,  480,  433 
Arthrodesis,  495 
Arthrolysis,  493 
Arthroplasty,  493 
Arthrospores,  42 
Arthrotomy,  479 
Artificial  anus,  754 
closure  of,  755 

larynx,  606 

leech,  96,  568 


INDEX 


1029 


Artificial  limbs,  1007 

nose,  5S9 

respiration,  ^:i 
Ascites,  operation  for,  777,  968,  969 
Ascococci,  42 
Asepsis,  51 
Aseptic  operation,  68 

fever,  166,  170 

thrombus,  266 
Ashhurst's  dressing  for  Jones'  position,  403 
Aspermia,  902 
Asphj'xia,  traumatic,  610 
Aspiration,  614 

for  hydronephrosis,  851 
chronic  abscess,  114 
empj-ema,  614 
joints,  475 
pericardium,  276 
Astereognosis,  506 
Asthenic  fever,  167 

inflammation,  93 
Astragalus,  dislocation  of,  472 

excision  of,  993 

fracture  of,  429 

tuberculous  disease  of,  486 
Astringents  in  inflammation,  98 
Ataxia,  506,  533 
Athelia,  620 
Atheroma,  290 
Atony  of  bladder,  871 
Atresia  ani  urethralis,  827 
vesicalis,  827 

of  cer\-ix,  931 

of  meatus,  566 

vaginalis,  827,  923 
Atrophic  scirrhus,  627,  218 
Atrophy,  see  special  regions 
Atropin,   hypodermic   injection   in   anes- 
thesia, 30 
Auditory  nerve,  injury  of,  354 
Auricle  of  ear,  accessory,  566 

wounds  of,  566 
Auriculotemporal  nerve,  excision  of,  352 
Auscultation,  in  diagnosis,  9 
Autochthonous  thrombus,  265 
Autoclave,  51 
Autogenous  bacterins,  50 
Autoinfection,  46 
Autointoxication,  166 
Autoprints,  5 
Autotransfusion,  165 
Avulsion  fracture,  375 
Axillary  artery,  compression  of,  313 

ligature  of,  326 
Azoospermia,  902 


Babcock's  operation    for.  varicose   veins, 

283 
Babes  rabic  tubercles  of,  183 
Bacelli's  sign,  613 

treatment  of  tetanus,  182 
Bacilli,  42 
Bacillus  aerogenes  capsulatus,  134,  43,  44 

anthracis,  1S5,  42 

chromogenic,  44 

coli  communis,  432,  107,  44 

diphtheria,  107 

drumstick,  178 

Ducrej^;  195,  896 

edematis  maligni,  134,  43 

flagellate,  43,  44 

influenza,  107 

lepra;,  190 

mallei,  187 

of  botulism,  43 

Oppler-Boas,  705 

photogenic,  44 

prodigiosus,  231 

pyocyaneus,  44,  107 

reading,  152 

sporogenes,  134 

tetani,  178,  43 

tuberculi,  208,  209,  107 

tj-phosus,  44 

virulence,  47 
Backache,  postoperative,  72 
Bacteremia,  168 
Bacteria,  42,  see  also  individual  bacteria, 

food  of,  43 
Bacterial  contamination,  45 

death,  44 

development,  43 

distribution,  42 

immunity,  47 

infection,  45 
methods  of,  46 

products,  44 
Bactericidal  serum,  48 
Bacterin,  50,  171 

autogenous,  50 

stock,  50 
Bacteriolysin,  48 
Bacteriolysis,  48 
Baking  apparatus,  99 
Balanitis,  898 
Balanoposthitis,  898 
Balfour's  cautery  excision,  725 
Bamberger's  sign,  275 
Band  splint,  390 
Bandages,  76 

see  also  special  bandages 


I030 


INDEX 


Bandages  of  abdomen,  85,  86 

of  chest,  85 

of  the  head,  78 

of  lower  extremities,  86 

of  perineum,  86 

of  the  trunk,  84 

of  upper  extremities,  81 

varieties  of,  77 
Bands,  peritoneal,  744 
Banti's  disease,  798 
Barbadoes  leg,  336 

Bardenheuer's  method  of   treating  frac- 
tures, 419,  420 
Barker's  operation  for  fractured  patella, 
423 

for  temporosphenoidal  abscess,  534 

of  excision  of  hip,  497 

solution  adrenalin  chlorid,  38 
for  local  anesthesia,  38 
spinal  anesthesia,  40 
Bartholin's  glands,  abscess  of,  922 
Bartlet's  sterilization  of  catgut,  61 

pyloroplasty,  724 
Barton's  bandage,  78 

fracture,  406 
Base  of  skull,  fracture  of,  517 
Baseball  finger,  979 
Basedow's  disease,  582 
Basedowified  goiter,  582 
Bassini's  operation  for  femoral  hernia,  813 

inguinal  hernia,  807 
Bastinelli  method  aspiration  of  blood,  611 
Battle's  sign,  519 
Bauden's    method    of    amputating    foot, 

1016 
Bazillenemulsion,  213 
Beatson's  operation  (oophorectomy),  220 
Beck's  operation  for  hypospadias,  883 

bismuth  paste,  124 
Bed  sores,  132 

in  spinal  injuries,  548 

palsy,  353 
Bellocq's  cannula,  593 
Bending  fracture  of  skull,  515 
Benign  tumors,  214 
Bennet's  fracture  of  the  thumb,  410 
Benzin,  54 

Beri-beri,  neuritis  in,  342 
Bevan's   operation   for  undescended  tes- 
ticle, 903 
Beyea's  operation  for  gastropexy,  711 
Biceps  femoris,  tenotomy  of,  368 
Bichat,  fissure  of,  503 
Bichlorid  of  mercury,  52 

solutions,  53 


Bier's  intravenous  anesthesia,  39 

osteoplastic  amputation,  1020 

treatment,  97,  211,  124 

danger  of,  in  arteriosclerosis,  292 
of  delayed  union  of  fractures,  386 
Bifid  tongue,  642 

Bigelow's  method  of  reducing  dislocation 
of  hip  joint,  468 

evacuator,  878,  602 
Bile  ducts,  stone  in  lower  common,  788 

upper  common,  787 
Bilharzia  hematobia,  846 
Biliary  cirrhosis,  778 

colic,  783 

fistula,  790,  678 

passages,  affections  of,  778 
operations  on,  788 

stasis,  781 
Bilious  ascites,  786 
Bilirubin  stones,  783 
Billroth's  operation  of  pylorectomy,  727, 

728 
Bilocular  hydrocele,  911 

stomach,  695 
Bimanual  examination,  920 
Binnie,  tenorrhaphy,  368 
Biondi,  pyloroplasty,  724 
Bipartite  scaphoid,  409 
Birth  mark,  226 

palsy,  356 
Bismuth  paste,  124 
Bistoury,  methods  of  holding,  70 
Bites,  dog,  182 

insect,  153 

snake,  154,  153 
Black  death,  135 

tongue,  644 
Blackness,  in  diagnosis,  6 
Bladder,  abscess  about,  873 

affections  of,  866 

atony  of,  871 

carcinoma  of,  873 

contracture  of  the  neck  of,  916 

examination  of,  867 

foreign  bodies  in,  876 

hernia  of,  801,  811 

inflammation  of,  871 

laxative,  71 

rupture  of,  674 

sounding  for  stone,  877 

sterilization  of,  67 

stone  in,  876,  879 

tuberculosis  of,  874 

tumors  of,  875 

ulcers  of,  875 


INDEX 


IO31 


Blake,  on  fractures,  381 
Blake's  suspension  and  extension  appara- 
tus, 3Q9 
with  the  Hodgen  splint,  418 

modification  of  Thomas'  splint,  380 
Bland  thrombus,  266 
Blank  cartridge  wounds,  145 
Blastomycetes,  51 
Biastomycetic  dermatitis,  51 
Blastomycosis,  246,  51,  18 
Blind  boil,  247 

fistula  anal,  832 
Blisters,  100,  155 

Blood,  chemical  examination  for  estima- 
tion of  renal  function,  846 

clot,  7 

healing  by  organization  of,  103 

coagulation  time,  13 

cysts,  2^5,  571,  572 

examinations  in  diagnosis,  11,  14 
in  diagnosis  of  tumors,  243 

letting,  in  inflammation,  95 

poisoning,  166 

pressure, 

in  cerebral  surgery,  507 

in  compression  of  brain,  512 

transfusion  of,  285 

tuberculo-opsonic  power,  210 

vessels,  injuries  of,  378 
changes  in,  91 
suture  of,  315 
Blueness,  in  diagnosis,  6 
Bodine's  operation,  757 
Boils,  247 
Bond  splint,  407 
Bone,  atrophy  of,  442,  375 

control  of  bleeding  from,  311 

contusions  of,  431 

cysts  of,  447 

diseases  of,  430,  7 

felon,  981 

gangrene  of,  434,  43 1 

grafting  of,  436 

gumma  of,  439 

hypertrophy,  443 

inflammation  of,  430 

injuries  of,  374 
varieties,  374 

necrosis  of,  434,  431 

riders,  364 

Rontgen  ray  in  diagnosis  of  disease  of, 
16,  447 

sarcoma  of,  447 

syphilis  of,  439,  198 

transplantation,  449,  382 


Bone,  tuberculosis  of,  438 

tumors,  445 

ulceration  of,  437 
Bony  ankylosis,  492 
Boric  (boracic)  acid,  54 
Borsch's  eye  bandage,  80 
Bougies,  urethral,  893 

esophageal,  660 
Bowel,  see  intestine 
Bowels,  after  operation,  72 
Bow-legs,  991 
Boxer's  ear,  566 
Braasch's  determination  of  site  of  renal 

stone,  858 
Brachial  artery,  compression  of,  313 
ligation  of,  327 

birth  palsy,  356 

infraclavicular,  355 

neuritis,  357 

plexus,  injury  of,  355 

supraclavicular,  355 
Brachio-cervical  bandage,  83 
Bradford  frame,  420 

Brain  and  membranes,  see  also  cerebral 
cerebellar,  skull,  head 

abscess,  533 

affections  of,  511 

compression  of,  512,  513 

concussion  of,  511,  514 

cysts  of,  512 

edema  of,  521 

fissures  of,  503 

foreign  bodies  in,  512 

gumma  of,  536,  512 

hernia  of,  523 

injuries,  effects  of,  512 

irritability  of,  512 

localization,  502 

prolapse  of,  524 

tumors,  534 

decompression  operation  for,  537 

wounds  of,  522 

non-penetrating,  522 
penetrating,  523 
Branchial  arches,  570 

carcinomata,  572 

clefts,  570 

cysts,  571 

fistulae,  570 
Brasdor's  operation  for  aneurysm,  303 
Brauer's    apparatus    for    prevention    of 

pneumothorax,  612 
Braun's  operation  for  salivary  fistula,  642 
Breast,  abscess  of,  621 

amputation  of,  628 


I032 


INDEX 


Breast,  bandages,  84 

carcinoma  of,  625 

chancre  of,  194 

congenital  malformations,  620 

cysts,  625,  632 
acinous,  626,  633 
interacinous,  633 
retention,  633 

diseases  of,  620 

hypertrophy  of,  621 

inflammation  of,  620 

neuralgia  of,  621 

nipples,  affections  of,  620 

syphilitic  affections  of,  624 

tuberculous  disease  of,  623 

tumors  of,  624,  621 
adenocele,  625 
carcinoma,  625 
cyst  adenoma,  625 
fibroadenoma,  624 
sarcoma,  625 

ulceration  of,  625 
Breath,  odor  as  diagnostic  agent,  10 
Brilliant  green,  55 
Brisement  force,  992 
Broad  ligament,  varicocele  of,  973 
Broadbent's  sign,  277 
Broca's  convolution,  506 

points  on  sliull,  502 
Brodie's  abscess,  438,  109 
Bronchial  affections  in  anesthesia,  35 
Bronchiectasis,  618 
Bronchocele,  578 
Bronchoscope,  601 
Bronchus,  foreign  bodies  in,  599 

stenosis  of,  600 
Bronze  patches,  in  diagnosis,  6 
Brood  capsules,  233 

Brophy's  operation  for  cleft  palate,  653 
Brown-Sequard's  paralysis,  541 
Brownian  movements,  44 
Bruise,  138 
Brush  burn,  139 

Bryant's  dressing  for  fractured  femur  in 
children,  420 

sign  for  dislocation  of  shoulder,  459 

triangle,  413 
Bubo,  193 

soft,  897 
Bubonocele,  802 
Buccal  nerve,  excision  of,  352 
Buck's  extension  apparatus,  414,  418 

in  treatment  of  hip-joint  disease,  485 
Bullet  wounds,  144 
Bunion,  997 


Burckhardt's  intravenous  etherization,  28 
Burns,  155 

cicatricial  contraction  following,  104 

Dupuytren's  classification,  155 

following  anesthesia,  35 

following  Rdntgen  ray,  19 

Hull's  paraf&n  treatment,  157 

severe,  indications  in,  157 

symptoms,  155 

treatment  of,  156,  159 
Bursae,  affections  of,  372 
Bursal  cysts,  572 
Bursitis,  372 

acute,  372 

adventitious,  372 

chronic,  372 

wounds,  372 
Bursting  fracture,  515,  518 
Buska  button,  247 
Butchers  wart,  250 
Button  suture,  141 

Cachexia,  in  diagnosis,  10,  217 

hypophyseopriva,  537 

strumipriva,  577 
Calcaneum,  see  os  calcis 
Calcification  of  thrombus,  266 
Calcium  carbonate  stones,  783 
Calculus,  see  special  regions 
Callosity,  248 
Calloway's  sign,  459 
Callus,  379 

compression  of  nerves  by,  345 
Calmette's  antivenene  serum,  154 

tuberculin  test,  211 
Calot's  method  in  Pott's  disease,  562 
Cammidge's  test  for  pancreatitis,  795 
Canalization  of  thrombus,  266 
Cancer,  216 
Cancer  en  cuirasse,  627 
Cancerous  cachexia,  217 
Cancrum  oris,  136 
Cannula  a  chemise,  311 
Capillary  hemorrhage,  307 

thrombi,  266 
Caput  succedaneum,  500 
Carbolic  acid,  53 

gangrene,  133 

poisoning,  53 

solutions,  53 
Carboluria,  53 
Carbon  dioxide  snow,  227 
Carbuncle,  247 

Carcinomata,   216,  217,  218,  51,  see  also 
special  regions 


INDEX 


1033 


Carcinomata,  treatment,  219 

use  of  Rontgen  rays  in,  252 
Carcinomatosis,  217 
Garden's   supracondyloid   amputation   of 

thigh,  1021 
Cardiac  failure  in  anesthesia,  34 

thrombi,  206 
Cardiolysis,  276 
Cardiospasm,  658 

Caries,    437,       431,    see    also    special 
regions 

fungosa,  438 

necrotica,  438,  558 

sicca,  438,  558 
Carnochan-Chavasse  operation  of  resec- 
tion of  superior  maxillary  nerve, 

351 
Carnot's  solution,  310 
Carotid  artery,  compression  of,  313 
ligature  of,  321 

gland,  584 
Carpal  bones,  dislocation  of,  464 

fracture  of,  409 
Carrel's  method  of  suture  of  arteries,  317 

technic,  57,  58 
Carrel-Dakin  method,  150 
Carron  oil,  158 
Carrying  angle,  401 
Cartilage,  inflammation  of,  92 

semilunar,  displacement  of,  471 

transplantation,  451 
Cartilaginous  tumors,  see  chondroma 
Caseation,  209 
Caseous  necrosis,  209 
Castration,  909 
Catalepsy,  180 
Cataplasm,  96,  99 
Catarrhal    inflammation,    93,    see    also 

special  regions 
Catgut,  60,  61 

iodized,  61 
Baitlett's,  61 
Claudius'  method,  61 
Congdon's  method,  61 
Hoffmeister's,  61 
Lee's,  61 
Catheterization,  916,  917 

dangers  of,  917 

for  enlarged  prostate,  917 

of  ureters,  843,  868 
Catheters,  891,  917 

fever,  895 

sterilization  of.  63 
Causalgia,  343 
Cautery,  100 


Cavernous  angioma,  226 

lymphangioma,  227 

sinus,  infection  of,  248 
injury  of,  353 
thrombosis  of,  532 
Cecca's  operation  for  varicose  veins,  284 
Cecocele,  801 
Cecopexy,  736 
Cecostomy,  755 
Cecum  in  hernic-e,  8or 

mobile,  736 

volvulus,  745 
Celiotomy,  666 

Cellular  theory  of  immunity,  48 
Cellulitis,  176,  see  special  regions 

acute  diffuse,  177 
symptoms,  177 
treatment,  177 

chronic,  176 

gangrenous,  177 
Cellulo-cutaneous  erysipelas,  175 
Celluloid  thread,  62 
Cementoma,  228 
Central  sarcoma,  446 
Cephalhematoma,  500 
Cephalotetanus,  180 
Cerebellar  abscess,  532,  570 

decompression,  537 
Cerebral  abscess,  532 

compression,  see  compression 

concussion,  511,  514 

hemorrhage,  515,  519,  521 

hernia,  523 

irritability,  512 

localization,  502 

sinuses,  hemorrhage  from,  510 
thrombosis  of,  531 

surgery,  507 

tumors,  537,  534,  see  also  brain,  cere- 
bellum, head,  skull 

vomiting,  535 

wounds,  522 
Cerebro-spinal  fluid,  escape  of,  545 

in  fracture  of  base,  517 

meningitis,  epidemic,  530 
Cerebrum,  see  brain 
Cerumen,  impacted,  566 
Cervical  adenitis,  338 

caries,  558 

endometritis,  935 

rib,  574 

sympathetic  ganglia,  excision  of,  361, 

584,  537 
vertebra,  dislocation  of,  547 

fracture  of,  see  fracture  of  spine 


I034 


INDEX 


CervLx  uterus,  931 
atresia,  931 
cysts  of,  933 
erosion,  933 

eversion  or  ectropion,  933 
hj-pertrophy,  932 

amputation  in,  932 
inflammation,  934 
laceration,  933 
stenosis,  931 
ulceration,  935 
Chancre,  192,  118 
foliaceous,  193 
Hunterian  or  ulcerative,  193 
indurated,  193 
mixed,  193 
nodular,  193 
parchment,  193 
redux,  193 
diagnosis  of,  194 
extragenital,  194 
finger,  194 
labial,  195 
urethral,  195 
Chancroid,  896,  194 
Change  of  color,  in  diagnosis,  6 
Chapped  lips,  637 
Charbon,  185 
Charcot's  disease,  489 

intermittent  fever,  779,  787 
joint,  489 
Charring,  155 
Chaulmoogra  oil,  190 
Cheiloplasty,  634 
Chemical  disinfection,  52 
gangrene  following,  133 
injuries,  155 
Chemotaxis,  43 
Chest,  concussion  of,  610 
contusion  of,  609 
hemorrhage  into,  610 
Chest,  surgery  of,  609 

wounds  of,  610 
Cheyne-Stokes  respiration,  512 
Chilblain,  160 
Chipault's  operation  for  spinal  deformitv, 

562 
Chloral  in  anesthesia,  28 
Chloramins,  57 
Chloroform,  36,  22,  21 

administration  of,  29,  28 
poisoning,  ss 
Chloroma,  229 
Choked  disk,  349 
Cholangiogastrostomy,  792 


Cholangiostomy,  793 
Cholangitis,  779,  790 
Cholecj-stectomy,  789 
indications,  789 
technic  of  operation,  790 
Cholecystenterostomy,  791 
Cholecystitis,  779,  786 
Cholecystogastrostomy,  791 
Cholecj'stostomy,  789 
indications,  789 
technic  of  operation,  790 
Choledochoenterostomy,  793 
Choledochogastrostomy,  793 
Choledocholithotomj'^,  792 
Choledocholithotrity,  792 
Choledochoplasty,  793 
Choledochostomy,  793 
Choledochotomy,  792 
Cholelithiasis,  781,  783 
Cholera,  49 
Cholesteatoma,  230 

Cholesterin-bilirubin-calcium  stones,  782 
Chondritis,  603 
Chondroarthritis,  480 
Chondrod3'stropia  fetalis,  442 
Chondroma,  223 
Chopart's  amputation,  1016 
Chordee,  885 
Chorea,  547 

Chorioepithelioma,  219,  954 
Chromoc\-stoscop3^,  845 
Chylocele,  912 
Chylothorax,  335 
Chylous  ascites,  335 

diarrhea,  335 

hydrocele,  912,  335 
Chyluria,  335,  847 
Cicatrices,  104 

Cicatrix  after  amputation,  1007 
Cinematic  amputation,  Vanghetti's  opera- 
tion, lOII 
Circular  amputation,  1003 

bandage,  77 

enterorrhaphy,  760 

resection,  696 
Circulation,  antiseptics  in,  171 
Circulatory  difficulties  during  anesthesia, 

34. 
Circumcision,  897 
Circumflex  nerve,  injury  of,  357 
Cirrhosis  of  liver,  operation  for,  777 
Cirsoid  aneurysm,  294,  226 
Civiale's  urethrotome,  893 
Clairmont-Erlich  myeloplasty,  461 
Clap,  885 


INDEX 


1035 


Clavicle  bandage,  84 

dislocation  of,  458 

fracture  of,  392,  84 
treatment,  392,  393 
Clavus,  248 

Claw  hand  in  ulnar  paralysis,  358 
Cleft  palate,  652 

of  lower  jaw,  636 

of  lower  lip,  636 

of  nose,  586 
Cloaca,  435 
Closed  dislocation,  455 

fracture,  374,  385 
Clot  embolism,  265,  289 
Clove  hitch,  456 
Clover's  inhaler,  30,  24 
Club-foot,  991 

hand, 978 

non-deforming,  998 
Coagulation  time,  13 
Coagulin  as  hemostatic  agent,  311 
Coaptation  suture,  141 
Cocain  hydrochlorid,  37 

poisoning,  37 
Cocci,  42 

Coccygeal  tumors,  553 
Coccygodynia,  412 
Coccyx,  excision  of,  412 

fracture  of,  412 
Cock's  operation  of  perineal  section,  894 
Codivilla,  non-union  of  fractures,  386 

transplantations,  450 
Codman  and  Chase  reduction  of  carpal 

dislocations,  464 
Cofifee  ground  vomit,  704 
Cohnheim's  theory  of  the  origin  of  tumors, 

214 
Coils,  high  frequency,  14 

induction,  14 
Coin  catcher,  660 
Cold,  159 

abscess,  114,  112,  438 

effects  of,  161,  159 

gangrene  following,  160 

in  treatment  of  hemorrhage,  310 
inflammation,  96 
sprains,  452 
Colectomy,  759 
Coley's  fluid,  231,  50,  220 
Colic,  see  special  regions 
Collapse,  163 

Collateral  circulation,  see  ligations 
Colles'  fracture,  407,  488 

immunity,  192 
Colloid  carcinoma,  218 


Colloid,  degeneration,  113 

goiter,  579 
Colon,  adenomata  multiple,  749 

carcinoma,  746 

idiopathic  dilatation  of,  734 
Colopexy,  838,  81  r 
Color,  abnormal,  in  diagnosis,  6 
Colostomy,  755 
Colpocleisis,  928 
Colporrhaphy,  924,  927 
Columna  nasi,  587 

Columnar  carcinoma,  218,  see  also  special 
regions 

celled  epithelioma,  218 
Coma,  diabetic,  515 

diagnosis  of,  514 

see  unconsciousness 
Combined  abdominal  and  vaginal  hyster- 
ectomy, 954 
Combustio  bullosa,  155 

erythematosa,  155 

escharotica,  155 
Comedo,  Rontgen  ray  in  treatment  of,  18 
Comminuted  fracture,  374 
Common  carotid  artery,  compression  of, 

ligation  of,  321 

iliac  artery,  ligation  of,  329 
Complement,  49 
Complementophile,  49 
Complete  dislocation,  455 

fracture,  374 

hysterectomy,  951 

inguinal  hernia,  803 

obstruction  of  bile  ducts,  787 

perineal  laceration,  operation  for,  927 
Complicated  fracture,  374 

dislocation,  455 
Complications  of  fractures,  378 
Composite  odontoma,  228 
Compound  dislocation,  455 

follicular  odontoma,  228 

fracture,  374,  384,  385 
treatment,  384 

ganglion,  366 
Compression,  cerebral,  512 

diagnosis,  513 

for  cure  of  aneurysm,  300 

fracture,  375,  5 15 

in  sprains,  453 

in  treatment  of  hemorrhage,  311 

in  treatment  of  inflammation,  98 

in  treatment  of  synovitis,  477 

of  the  heart,  274 

of  nerves,  345 


1036 


INDEX 


Compression,  pathological  changes,  512 

symptoms,  512 

treatment,  515 
spinal  cord,  547 
Concealed  menstruation,  954 
Concussion,  511,  see  special  regions 

of  the  heart,  273 
Condensing  ostitis,  430 
Condition,  social,  in  diagnosis,  3 
Condylomata,  198,  197 
Congenital  affections,  see  special  regions 

aneurysm,  296 

cystic  hygroma,  227 

elephantiasis,  344 

fecal  fistula,  733 

fractures,  375 

indirect  inguinal  hernia,  S03 

s\'philis,  191,  206,  439 

torticollis,  573 
Congestive  dysmenorrhea,  956 
Conical  stump,  1007 
Conjunctivitis,  gonorrheal,  886 

in  anesthesia,  35 
Connective   tissue,  inflammation   of,   see 
cellulitis 

tumors,  220,  215,  228 
Consecutive  hemorrhage,  307 

aneurysm,  296 
Consistency  of  tumors,  240 
Constitutional  treatment,  loi 
Continued  thrombus,  266 
Contraction,  cicatricial,  104 

Dupuytren's,  980 

excessive,  104 

Volkmann's,  976 

see  special  regions 
Contre  coup,  516,  519 
Contused  wounds,  143 
Contusions,  139,  138,  see  special  regions 
Convolution  angular,  504 

supramarginal,  504 
Coolidge  tube,  15 

Cooper's  method  of  reducing  dislocations 
of  elbow  joint,  462 

shoulder  joint,  461 
Coracoid,  fracture  of,  395 
Core,  247 
Cornea,  inflammation  of,  207 

ulcer  of,  209 
Corns,  248 

Cornu  cutaneum,  249 
Corona  Veneris,  197 
Coronary  artery,  compression  of,  213 
Coronoid  process,  fracture  of,  405 
Corporeal  endometritis,  935 


Corpus  luteum,  cysts  of,  966 

Corradi's  method  of  treating  aneurysms, 

301 
Corrosive  sublimate,  52 

poisoning,  52 
Corsetage,  149 
Costal  cartilage,  dislocation  of,  465 

fracture  of,  392 
Cotteril  operation  for  hydrocephalous,  529 
Cotton's  method  in  fracture  of  os  calcis, 

430 
Coughing  in  anesthesia,  34 
Counterextension,  456 
Counterirritation,  100 
Courvoisier's  law,  788 
Coverings  of  hernia,  801,  see  also  special 

herniae 
Cowper's  glands,  inflammation  of,  890 
Coxa  valga,  989 

vara,  989,  413 
Coxalgia,  483    * 
Coxitis,  483 
Cracked  lip,  637 

nipples,  620 

pot  sound,  516 
Craniocerebral  topography,  502 
Craniotabes,  440 
Cranium,  affections  of,  511,  524,  see  head, 

skull,  brain,  cerebral 
Cravat,  81 

Gerdj''s  extension,  88 
Creolin,  54 
Crepitus,   377 

in  diagnosis,  8,  7 

in  fractures,  377 

in  joints,  7,  8 
Cretinism,    577 
Crile's  anociassociation,  31 

clamp,  165 

pneumatic  rubber  suit,  165 

treatment  of  shock,  165 
Crisis,  Dietl's,  849 
Crooked  nose,  592 
Crookes  tube,  14 
Crossed  bandage,  79,  80 

embolism,  267 

paralysis,  353,  506 
Croupous  inflammation,  93 
Crj'ptogenic  septicemia,  168 
Cryptorchism,  902 
Cubitus  valgus,  401 

varus,  401 
Cultures,  see  bacteria 
Cuneiform  osteotomy,  991 
Cup  and  stem  pessary,  945 


INDEX 


1037 


Cupping,  q6 

Curettage  of  uterus,  936 

dangers,  936 
Curling's  ulcer,  156 

Curvature     of     legs,     see     genu     varum 
of  spine,  554 
angular,  557 
lateral,  554 
rachitic,  554 
Cushing's  decompression  operation  for  in- 
tracranial pressure,  510 
operation  for  hydrocephalus,  529 
operation  for  penetrating  wounds  of 

the  brain,  523 
operation    for    the    removal    of   the 
Gasserian  ganglion,  353 
Cut  throat,  575 

Cutaneous  defects,  plastic  operations,  256 
gangrene,  multiple  areas  of,  24S 
nerves  areas  of  distribution,  359 
neurotibromata,  344 
Cylindrical  celled  epithelioma,  218 
C\'lindroma,  231 
Cyrtometer,  Horsley's,  503 
Cystadenoma,  see  special  regions,  216 
Cystic  duct,  gall-stones  in,  786 
goiter,  579 
hygroma,  572,  227 
lymphangioma,  572 
Cysticercus  cellulosae,  235 
Cj'sticotomy,  791 
Cystitis,  871 
acute,  872 
chronic,  873 
in  gonorrhea,  886 
in  spinal  affections,  563 
Cystocele,  924,  801 
Cystosarcoma  of  breast,  625 
Cystoscope,  867 
Cystoscopic  pictures,  869 
Cystoscopy,  867 
Cystotomy,  perineal,  880 

suprapubic,  879 
Cysts,  232,  214 

degeneration,  235 
distension,  232 
exudation,  232 
bursre,  572 
hygroma,  233 
serous,  232 
extravasation,  232 

blood,  233 
new  formation,  233 
blood,  233 
cysticercus  cellulosa,  235 


Cysts,  new  formation,  dermoid,  233 
foreign  bodies,  233 
parasitic,  233 
retention,  232 
mucous,  232 
salivary  or  ranula,  232 
wens  or  sebaceous,  254,  232 
see  also  special  regions 
Cytodiagnosis,  545,  210 
Cytophile,  49 

DaCosta's     operation     for     nephropex}', 

863 
Dactylitis,  syphilitic,  439 

tuberculous,  438 
Dakin's  oil,  58 
Dakin's  solution,  56 

Carrel  technic  in,  57,  58 

Daufresne's  method,  56 

hypochlorite  content,  57 
Dakin  and  Dunham  theory,  57 
Dandy  differentiation  of  tv'pes  of  hydro- 
cephalus, 527 
Dawbarn's      operation      for      inoperable 
growths  about  the  face,  219 

Debridement,  148 
Decapsulation  of  kidney,  864 
Deciduoma  malignum,  954,  219 
Decortication,  pulmonary,  617 
Decubital  gangrene,  132 
Decubitus,  132 

Deformities,  see  special  regions 
Degeneration,  amyloid,  113 

cysts  of,  235 

gummatous,  199 
Dehelley  method,  sequestrotomy,  436 
Delayed  primary  suture,  149 

union  of  fractures,  385 
Delbet's  operation  for  varicose  veins,  284 
Delhi  sore,  247 
Delirium,  172 

nervosum,  173 

of  collapse,  174 

traumatic,  173 

treatment,  174 

tremens,  173 
Deltoid  bursa,  373 
De  Morgan's  spots,  252 
Demigauntlet  bandage,  82 
Dental  cysts,  648 

nerve,  inferior,  resection  of,  352 
Dentate  fracture,  374 
Dentigerous  cyst,  228,  649 
Deodorizer,  51 
Depressed  fracture,  374 


I038 


INDEX 


Depressed  scar,  105 

of  skull,  516 
Dermatoses,  precancerous,  252 
Dermoid  cysts,  233,  641 

see  also  special  regions 
Desault's  bandage,  84,  394 
Desjardin's  pancreatic  point,  795 
Desmoid,  365 
Diabetes,  129 

traumatic,  166 
Diabetic  coma,  515 
gangrene,  129 
Diagnosis,  general  remarks  on,  i 
of  tumors,  235 

see  special  regions 
Diapedesis,  92 
Diaphany,  6 

Diaphoretics  in  sepsis,  172 
Diaphragmatic  hernia,  817 

rupture,  817 
Diaphysitis,  432 
Diarrhea,  chylous,  335 
Diastasis,  376 

of  recti  abdominis  muscles,  816 
Dichloramin-T,  Lee's  technic,  58 
solution,  56,  58 
for  burns,  158 
Diet  before  operation,  65 
Dietl's  crisis,  849 
Differential  blood  count,  13 
Diffuse  aneurysm,  296 

hydrocele  of  the  cord,  911 
phlegmon,  177 
septic  osteomyelitis,  432 
Digital  compression  of  arteries,  301 

chancre,  194 
Dilatation,  see  special  regions 
Dilger,    treatment   of   delayed   union    in 

fractures,  386 
Diphtheritic  inflammation,  93 
Diplococci,  42 
Diplococcus  gonorrheae,  885 

intracellularis  meningitidis,  530 
Direct  fracture,  375 
gangrene,  132 
inguinal  hernia,  804 
Disarticulations,  999 
Discission  of  lung,  617 
Discoloration  in  diagnosis,  6 

in  inflammation,  104 
Disinfectant,  51 
of  hand,  64 
Disinfection,  42,  see  sterilization 
Dislocations,  453 
compound,  457 


Dislocations,  congenital,  453 
old  unreduced,  457 
pathological,  455 
traumatic,  455,  456 
treatment,  456 

see  also  special  regions 
Dissecting  aneurysm,  296 
Dissection  wounds,  152 
Distention  cysts,  232 

of  bladder,  870 
Distortions  by  X-ray,  17 
Disunited  fracture,  386 
Diuretics,  in  sepsis,  172 
Diurnal  pollutions,  900 
Diverticulitis,  734 
Diverticulum  of  esophagus,  657 

of  Meckel,  733 
Dobbertin's  pyloroplasty,  724 
Dorrance    and    Ginsburg's    method    for 

transfusion  of  blood,  286 
Dorsal  abscess,  559 

dislocation  of  hip,  467,  466 
Dorsalis  pedis  artery,  ligature  of,  334 
Double-barrel  stenosis,  735 
Double  inclined  plane,  418 

pedunculated  flap,  259 

T-bandages,  85 
Douche,  99 

Dowd's  operation  for  cancer  of  lip,  638 
Drainage  materials,  71 

indications  for,  70 

for  infection,  73 

objections  to,  71 

of  wounds,  71 

material,  71 

tubes,  71 
Dressings,  62 

changed,  73 

fixed,  89,  76 

of  wound,  71 
Dry  gangrene,  126 
Dubreuil's  amputation  at  the  wrist  joint, 

lOIO 

Duchenne-Erb  paralysis,  355 
Duct  cancer  of  breast,  627 

papilloma  of  breast,  625 
Dudley's    operation    for    anteversion    of 

uterus,  939 
Duga's  sign,  459 
Dunham  and  Moschowitz  treatment  in 

pyothorax,  614 
Duodenal  ulcer,  732 
Duodenocholedochotomy,  792 
Duodenojejunal  hernia,  819 
Duodenostomy,  754 


INDEX 


1039 


Duodenum,  stenosis  of,  733 

ulcer  of,  732 
Dupuytren's  ami)utation.  1014 

classification  of  burns,  155 

contraction,  980 

fracture.  427,  471 

splint,  42S 
Duraendothelioma,  230 
Dura  mater,  hematoma  of,  529 

inflammation  of,  529 

injuries  of,  520 
Dural  separator,  Horsley's,  508 
Duration,  in  diagnosis,  4,  5 

of  tumor,  236 
D\-es  as  disinfectants,  55 
Dysentery,  51 
Dysmenorrhea,  955 

congestive,  956 

mechanical  or  obstructive,  956 

membranous,  956 

neuralgic,  955 

ovarian,  956 
Dyspeptic  ulcer  of  tongue,  644 
Dystrophia  adiposogenitalis,  537 

Ear,  affections  of,  566 

accessory  auricles  of,  566 

atresia,  566 

congenital  fistula  and  sinuses,  566 

foreign  bodies,  567 

hematoma,  566 

hemorrhage  from,  518 

sterilization  of,  67 

wounds,  566 
Eburnated  osteoma,  225 
Ecchondroma,  224 
Ecchondrosis,  224 
Ecchymosis,  138,  6 
Echinococcus,  234 

see  also  special  regions 

cysts,  233 
Eck's  fistula,  777 
Ecthyma  syphihtic,  197 
Ectocyst,  233 
Ectopia  testis,  902 

vesicae,  866 

viscerum,  814 
Ectopic  kidney,  843 

pregnancy,  961 
Ectotoxin,  45 
Ectrodactylism,  979 
Eczema,  of  nipple,  621 
Eczematous  ulcer,  122 
Edebohl's  operation  for  floating  kidney, 
863 


Hdema,  7 

angioneurotic,  603 

anthrax,  186 

hysterical,  7 

in  diagnosis,  7 

lymjjhatic,  336 

malignant,  42 

see  special  regions 
Eflleurage,  98 
Effusion  into  joints,  490 
Ehrlich's  theory  of  immunity,  48 
Ehrlich's  "606,"  203 
Eighth  nerve,  injuries  of,  354 
Elastic  bandage,  122 
Elbow  joint,  ankylosis  of,  494 

disarticulation  of,  1012 

dislocation  of,  462 
varieties,  462 

effusion  into,  476 

examination  of,  400 

excision  of,  496 

fractures  of,  401 

tuberculosis  of,  482 
Electrical  injuries,  161 

symptoms,  162 

treatment,  162 
Electricity  for  affections  of  nerves,  346 

muscles,  346 
Electrohemostasis,  310 
Electrolysis  for  aneurysm,  301 

for  angioma,  227 

for  cirsoid  aneurysm,  294 

for  goiter,  580 

for  keloid,  254 

for  uterine  fibroids,  948 
Elephantiasis,    336 

Arabum,  336 

Graecorum,  190 

neuromatosa,  344 

of  tongue,  643 

pseudo,  336 
Elephantoid  fever,  336 
Elevation  in  hemorrhage,  310 

in  inflammation,  95 
Eleventh  nerve,  affections  of,  354 
Elliptical  method  of  amputating,  1004 
Elsberg  apparatus  in  anesthesia,  27 
Elting's  method  in  operation  for  fistulse 

in  ano,  834 
Embolic  aneurysm,  296 

gangrene,  130 
Embolism,  267 

air,  270 

sj'mptoms,  270 
treatment,  270 


1 040 


INDEX 


Embolism,    diagnosis  between  embolism 
and  thrombosis,  268 

effects  of,  267 

fat,  271 

symptoms,  271 
treatment,  272 

pulmonary,  269 

site  of  impaction,  267 

symptoms,  268 

treatment,  269 
Embryonic  tissue,  92 

tumors,  214 
Emissions,  involuntary  seminal,  900 
Emmet's  method  for  treating  inversion  of 
uterus,  946 

perineorrhaphj',  925 

trachelorrhaphy,  933 
Emphysema,  611 

in  diagnosis,  7 

subcutaneous,  263 
Emphysematous  gangrene,  134 
Emprosthotonos,  179,  11 
Empyema,  aspiration  of,  614 

necessitatus,  613 

of  antrum,  597 

of  appendix,  766 

of  frontal  sinuses,  596 

of  gall-bladder,  780,  786 

of  joints,  477 

of  pericardium,  275 

of  pleural  cavity,  613 
Enantobiosis,  46 
Encapsulated  empyema,  613 
Encephalitis,  529 
Encephalocele,  525 

of  breast,  626 
Encephaloid  carcinoma,  218 
Enchondroma,  224 
Encysted  hydrocele  of  cord,  911 
testis,  911 

infantile  hernia,  804 
Endarteritis,  290,  199 

obliterans,  291 
Endoaneurysmorrhaphy,  303 
Endocervicitis,  935 
Endocyst,  233 
Endospore,  42 
Endotoxin,  45 

End-to-end  anastomosis,  of  blood-vessels, 
317 

of  bowels,  760 

of  nerves,  347 

of  ureter,  865 

of  vas  deferens,  912 
Endometritis,  934,  935 


Endometritis,  varieties,  934,  935,  936 

Endostosis,  225 

Endothelial  cancer,  230 

Endothelioma,  341,  230 

Enlarged  prostate,  915 

Enterectomy,  758 

Enteroanastomosis,  760 

Enterocele,  801 

Enteroclysis,  165,  288 

Enteroepiplocele,  801 

Enteroliths,  748 

Enteroperitoneal  tuberculosis  of  the  intes- 
tine, 739 

Enteroptosis,  739 

Enterorrhaphy,  754 
circular,  760 

Enterospasm,  748 

Enterostomy,  754 

Enterotomy,  753 

Enterovaginal  fistula,  928 

Enucleation  of  thj-roid  tumors,  580 
uterine  fibroids,  vaginal,  949 

Enzymes,  44 

Eosinophilia,  13 

Epicritic  nerve  fibers,  346 

Epidemic  cerebrospinal  meningitis,  530 

Epidermic  inlay,  261 

Epidermization,  103 

Epididymis,  cysts  of,  911 

Epididymitis,  904 

syphilitic,  906,  198 
tuberculous,  905 

Epigastric  hernia,  816 

Epiglottis,  ulceration  of,  603 

Epilepsy,  537,  538 

Epiphyseal  diastasis,  376 

separation  in  diagnosis,  7 

Epiphyses,  separation  of,  376,  375 

Epiphysitis,  432 
syphilitic,  440 

Epiplocele,  801 

Epiplopexy,  operation  of,  for  ascites,  777 

Epispadias,  882 
complete,  866 

Epispastics,  100 

Epistaxis,  592 

Epithelial  odontoma,  227,  649 
tumors,  215 
benign,  215 
adenoma,  216 
papilloma,  215 
treatment,  216 
malignant  or  carcinoma,  216 
epithelioma,  217 
glandular  or  acinous,  218 


INDEX 


104I 


Epithelial    tumors,    malignant   or   carci- 
noma, treatment,  219 
see  also  special  regions 
Epithelioma,  217,  195,  196 
Epulis,  649,  230 
Equinia,  187 
Erasion,  495 
Erethistic  shock,  164 
Ergot,  gangrene,  130 
Erosion,  aneurysmal,  296 
Eruption,  fever  of,  196 
Erysipelas,  175,  174 

cause.  174 

curative  action  of,  in  sarcoma,  231 

neonatorum,  175 

salutaire,  175 

symptoms,  174 
Erysipeloid,  176 
Erythema,  155 

contusiformis,  245 

gangrenous,  248 

nodosum,  245 

syphilitic,  197 
Erythromelalgia,  999 
Esmarch  band,  312,  40 

cold  coil,  96 

inhaler,  28 

mask,  28,  29 

method   of  amputation   of   the   hip, 
1024 

tendon  lengthening,  369 
Esophageal  bougies,  660 
Esophagectomy,  663 
Eso^hagismus,  660 
Esophagoplasty,  664,  662 
Esophagoscope,  656 
Esophagostomy,  662 
Esophagotomy,  659,  662 
Esophagus,  affections  of,  656 

atresia  of,  657 

burns  of,  159 

congenital  malformations  of,  657 

dilatation  of,  658 

diverticula  of,  657 

excision  of,  663 

fistula  of,  657 

foreign  bodies  in,  659 

idiopathic,  658 

rupture  of,  610 

sterilization  of,  65 

stricture  of,  660 

fibrous  or  cicatricial,  66 r 
inorganic  or  spasmodic,  660 
malignant,  662 
organic,  661 

66 


Esophagus,  wounds  of,  658 

Estlandcr's    operation    of    thoracoplasty, 

617 
Ether,  24,  54,  35,  28,  21 

contraindications  to  use  of,  21 
pneumonia,  35 
stages  of,  25 
Ethmoid,  diseases  of,  597 
Ethyl  bromid,  31 

chlorid,  30,  22,  21 
Eucain  hydrochlorid,  uses  of,  37 
Eupad,  56 
Eusol,  56 

Evacuator,  Bigelovv's,  878,  602 
Evaporating  lotions,  97 
Ewart's  sign,  275 
Examination,  general,  10,  11 

for  tumor  diagnosis,  244,  238 
Excessive  callus,  379 

Excision  of  joints,  495,  see  also  special 
joints 
of  tumors  for  examination,  243 
Exclusion  of  intestine,  764 

of  pylorus,  723 
Excoriation,  139 
Exfoliative  endometritis,  936 
Exhaustion,  163 
Exomphalos,  814 
Exophthalmic  goiter,  582,  19 
Exophthalmos,  582 
Exostoses,  225 
Exothymopexy,  584 
Exothyreopexy,  580 
Explosive  fracture  of  skull,  516 
Exploratory  incision,  6 
Extension,  Buck's,  414,  418 
External  anthrax,  186 
prognosis,  187 
treatment,  187 
epicondyle  fracture,  403 
carotid  artery,  ligation  of,  322 
iliac  artery,  compression  of,  313 

ligation  of,  330 
hemorrhage,  307 
inguinal  hernia,  802 
popliteal  nerve,  affections  of,  360 
urethrotomy,  894 
Extirpation  of  aneurj'sm,  304 
Extraarticular  fractures,  374 
Extracapsular  fracture  of  femur,  415 
Extracranial  complications  of  otitis  media, 

567 
Extradural  abscess,  532 

hemorrhage,  519,  551 
Extragenital  chancres,  194 


I042 


INDEX 


Extramedullary  hemorrhages,  spinal,  555 
Extraparietal  inguinal  hernia,  805 
Extraperitoneal  rupture  of  bladder,  674 

of  tubal  gestation,  961 
Extrauterine  pregnancy,  g6i,  963 
Extravasation  cysts,  232 

of  blood,  138 

of  urine,  884 
Extra  vesical  prostatectomy,  918 
Extremities,  975 

movements  of,  in  anesthesia,  25 
Extroversion  of  bladder,  866 
Exuberant  granulations,  103 
Exudation,  91 

cysts,  232 
Eye,  bandages  of,  79,  80 

fatigue  in  operations,  69 

Facial  artery,  compression  of,  313,  324 
ligation  of,  321 

cleft,  636 

expression,  in  diagnosis,  10 

nerve,  affections  of,  353 

neuralgia,  350 

paralysis,  353,  567 

vein,  thrombophlebitis,  248 
Facies,  Hippocratica,  11 

in  diagnosis,  11 

ovariana,  967 
Fallopian  tubes,  affections  of,  957 

congenital  abnormalities  of,  957 

displacements  of,  957 

inflammation  of,  957 

pregnancy  in,  961 

tuberculosis  of,  960 

tumors  of,  961 
False  ankylosis,  494 

incontinence  of  urine,  870 

joints,  385 

keloid,  253,  220,  105 

neuroma,  343 

passages,  895 
Farcy,  187 
Fascia  strips  for  suture,  62 

transplantation,  370 
Fasciotomy,  993 
Fat  embolism,  271 

necrosis,  794 

transplantation,  263 
Fatty  tumors,  see  lipoma 
Fauces,  erysipelas  of,  176 
Favus,  51 

Rontgen  rays  in  treatment  of,  18 
Fear,  abolished  in  anesthesia,  31 
Fecal  fistula,  927,  928,  758 


Fecal  fistula,  umbilical,  677 

impaction,  749 
Feeding,  nasal,  182 
Fell-0'Dwyer  apparatus,  34,  612 
Fell's  method  of  artificial  respiration,  34 
Felon,  981 

subcutaneous,  981 
subcuticular,  981 
subperiosteal,  981 
synovial  or  thecal,  982 
Female   genital   organs,   examination   of, 

919 
Femoral  adenitis,  338 

artery,  compression  of,  313 

ligation  of,  331 
hernia,  812,  805 

operation  for  radical  cure,  812 
signs,  812 

strangulated,  821,  132 
vein,  inflammation  of,  277 
Femur,  fracture  of,  412 
condyles,  420 
extracapsular,  415 
intracapsular  fracture  of  neck  of, 

412 
longitudinal,  421 
shaft,  417 

symptoms,  417 

treatment,  417 

supracondylar,  420 

T-  or  Y-shape,  420 
trochanters,  416 

separation  of,  416 
upper  extremity,  412 
separation  of  lower  epiphysis,  420 

upper  epiphysis,  416 
supracondyloid  amputation,  102 1 
Ferguson's  amputation  at  the  ankle  joint, 
1017 
speculum,  919 
Ferments,  44 
Ferrarini   operation   for   salivary   fistula, 

642 
Fever,  166 

adynamic,  167 

aseptic,  166,  170 

asthenic,  167 

catheter,  895 

Charcot's  intermittent,  779,  787  ■, 

cocain,  37 

elephantoid,  336 

fracture,  377 

hectic,  167,  113 

hemorrhagic,  308 

hepatic,  774 


INDEX 


1043 


Fever,  inflammatory,  167 

iodoform,  55 

post-operative  (Chapter  XII) 

rcactionar)',  166 

resorption,  166 

septic,  167 

splenic,  185 

sthenic,  167 

syphilitic,  ig6 

urethral,  8q5 
J-ibrinous  inflammation,  93 
Fibroadenoma,  216 
Fibroblasts,  102,  92 
Fibrocystic  disease  of  jaw,  227,  649 
Fibroids  of  uterus,  947 
Fibrolipoma,  221,  222 
Fibromata,  220 
Fibromyoma,  225,  947 

of  uterus,  947 
Fibrosarcoma,  230 
Fibrosis,  arteriocapillary,  290 
Fibrous  ankylosis,  491 

epulis,  230 

goiter,  579 

odontoma,  228 

polyps,  594 

tissue  formation,  102 

union  of  fractures,  385 
Fibula,  dislocation  of,  471 

fracture  of,  425,  426 

upper  end, 425 

shaft,  426 
Fifth  nerve,  operations  on,  350 
Figure  8  bandage,  77 

for  neck  and  axilla,  83 

of  leg,  87 

of  shoulders,  84 
Filaria  sangunis  hominis,   336,  394, 

267,  13 
Fingers,  amputations  of,  1008 

chancre  of,  194 

deformities  of,  979 
Finnej^'s  pyloroplasty,  725 
Finsen  light  in  treatment  of  epithelioma, 
252 

lupus,  251 

tuberculosis,  211 
Fission  fungi,  42 
Fissure  of  Bichat,  503 

longitudinal,  502 

parietooccipital,  504 

Rolando,  503 

Sylvius,  504,  503 
Fissured  fracture,  374 

of  skull,  516 


Fissures  of  nij)|)le,  620 

J'istula,  125,  see  also  special  regions 

lymphatic,  336 
Flagella,  see  bacteria 
Flail  joint,  495 
Flapless  amputation,  1006 
Flap  splitting  perineorrhaphy,  926 
Flaps  in  amputations,  1002 

direct  transference,  258 

indirect  tranfserence,  258 

{)edunculated,  257 

sliding,  259 

sloughing  in,  1006 
Hat-foot,  994 

plate,  996 
Floating  kidney,  849 
Fluctuation,  7 

P'luhrer's  aluminium  probe,  523 
Fluid  tumors,  240 
Fluoroscope,  16,  15 

localizing  foreign  bodies  by,  16 
Flush  tank  symptom,  851 
Focal  epilepsy,  538 
Foerster's  operation,  544 

for   resection   of   posterior   roots   of 
spinal  cord,  544 
Follicular  goiter,  579 

odontoma,  228 
Fomentation,  99 
Food,  after  operation,  73 
Foot,  amputations  of,  1014 

bandage,  86 

deformities  of,  991 

drop,  361 

fractures  of  phalanges,  430 

hollow,  996 

perforating  ulcer  of,  999 
Forbes'  amputation  of  foot,  1017 
Forcipressure   treatment   in   hemorrhage, 

314 
Ford's  suture,  141 
Forearm,  amputation  through,  loio 

dislocation  of,  462 

fracture  of  both  bones,  408 
Foreign  bodies,  see  special  regions 

Rontgen  rays  in  diagnosis  of,  16 
Formaldehyd,  54 
Formalin,  54 

Forward  dislocation  of  hip,  468,  466 
Fossa,  fractures  involving,  518 
Four-tailed  bandage,  80 
Fourth  nerve,  paralysis  of,  350 
Fowler's  operation  of  pulmonary  decorti- 
cation, 617 

position,  681 


1044 


INDEX 


Fractional  sterilization,  60 
Fracture  box,  396 

dislocation,  385,  427,  455 

fever,  377 
Fractures,  374,  see  also  special  bones 

causes  of,  375 
exciting,  375 
predisposing,  375 

complications  of,  378,  385 

diagnosis  of,  378,  7 

repair  of,  378 

Rontgen  ray  in  diagnosis  of,  16,  378 

signs  of,  377 

special,  386 

treatment  of,  379,  384 
ambulatory,  381 
operative,  381 
reduction  or  setting,  380 
restoration  of  function,  381 
retention  of  immobilization,  380 
ununited,  385 

varieties  of,  374 
Fragilitas  ossium,  442 

varieties,  442 
Frank's  operation  of  gastrostomy,  707 
Free  transplantation  in  neurorrhaphy,  348 

of  fascia,  370 
Freezing,  159 

anesthesia,  37 

symptoms,  161 

treatment,  161 
French  method  of  rhinoplasty,  591 
Friction,  100 

Friedel's  operation  for  varicose  veins,  283 
Friedreich's  sign,  277 

operation  for  phthisis  pulmonalis,  61S 
Frog  nose,  586 
Frontal  sinuses,  affections  of,  596 

empyema  of,  596 

hydrops  of,  596 

inflammation,  596 

trephine  of,  597 

tumors  of,  597 
Frost  bite,  159 

gangrene  in,  160 

s>Tnptoms,  159 

treatment,  160 
Fulguration,  219 
Fulminating  appendicitis,  767 
Fumigation     by     mercury     in     treating 

syphilis,  202 
Fungi,  see  bacteria 
Fungus  cerebri,  524 

hematodes,  218 

testis,  906 


Funicular  inguinal  hernia,  803 
Furbringer's    method    of   sterilization  of 

hands,  64 
Furuncle,  247 
Fusiform  aneurysm,  296 

Gait  in  diagnosis.  11 
Galactocele,  633 
Gall-bladder,  affections  of,  780 

new  gall-bladder,  791 

papilloma  of,  780 

rupture  of,  672 

stones  in,  785 
Gall-stones,  781 

in  intestine,  748 

pancreatitis  due  to,  793 

symptoms  of,  783 
Ganglion,  365 

compound  palmar,  366 
Gangrene,  126 

direct,  132 
bed  sores,  132 
burns   and   scalds    (Chapter   XI), 

155 
corrosive  chemicals,  133 
crushes,  132 
frost    bites     (Chapter    XI),    155, 

159 

prolonged  pressure,  132 

X-ray,  134 
dry,  126,  131 
emphysematous,  134 
etiology,  127 
indirect,  127 

Ainhum,  130 

diabetic,  129 

embolic,  130 

ergot,  130 

ligature  of  principal  artery,  131 

obstruction  of  principal  artery  and 
vein,  131 

post-febrile,  129 

presenile,  128 

Raynaud's  or  symmetrical,  1 29 

spontaneous,  128 

thrombosis  of  artery,  131 

treatment,  128 
micro  bic,  127,  134 

emphysematous,  134 

hospital,  134 

malignant  edema,  134 

multiple  cutaneous  areas,  248 
moist,  126 
signs  of,  126 
termination,  127 


INDEX 


I04S 


Gangrenous  appendicitis,  767 

cellulitis,  177 

inflammation,  93 

pancreatitis,  795 

stomatitis,  136 

urticaria,  248 
Garre-pneumectomy  operation,  618 
Gartner's  duct,  cj'st  of,  967,  232 
Gaseous  swelling  in  tumor,  240 
Gas  gangrene,  symptoms  of,  135 

treatment,  136,  134 
Gasoline,  54 

Gasserian  ganglion,  removal  of,  352 
Gastrectasia,  699 
Gastrectomy,  725 

complete  or  total,  732 

partial,  725 

subtotal,  726 

Stewart's  method,  728 
Gastric  fistula,  698 

hemorrhage,  694 

lavage,  706,  23 

tetany,  695 

ulcer  and  its  effects,  689 
Gastritis  obliterans,  706 
Gastrodiaphany,  702 
Gastroenterostomy,  698 

vicious  circle  after,  722 
Gastrogastrostomy,  697 
Gastrointestinal    tract,    sterilization     of, 

65 
Gastrojejunostomy,  728 
Gastrolysis,  695 
Gastromesenteric  ileus,  700 
Gastropexy,  711 
Gastroplasty,  697 
Gastroplication,  711 
Gastroptosis,  703 
Gastrorrhagia,  694 
Gastrostomy,  707,  662 
Gastrotomy,  707 
Gaucher's  disease,  798 
Gauntlet  bandage,  82 
Gauze  bandage,  76 

pads,  62 
Gelatin  as  a  hemostatic,  310 

injection  of  aneurysms,  300 
Gelatinous  carcinoma,  218 
General  anesthesia,  21 

lymphadenosis,  339 
Genital  chancre,  194 

organs,  female,  919 
male,  882 
Genitourinary  canal,  843 
Genupectoral  position,  940 


Genu  recurvatum,  991 

rhachiticum,  989 

staticum,  990 

valgum,  989 

varum,  990 
Gerdy's  extension  cravat,  88 
Germicide,  52,  51 
Germinal  infection,  46 
Gerster's    operation    for    amputation    of 

breast,  629 
Giant-celled  sarcoma,  230 
Gibson's  bandage,  78 

operation,  755 
Giere-pneumectomy  operation,  618 
Gigli  saw,  508 

Gilles'   modification  in  rhinoplasty,   589 
Gilliam-Ferguson  operation  of  shortening 

the  round  ligaments,  943 
Girard,  pyloroplasty,  724 
Glanders,  187,  188 
Glands,  lymphatic,  affections  of,  340 

malignant,  340 

mesenteric,  687 
Glandular  carcinoma,  218 
Glass  arm,  362 
Glaucoma,  361 
Gleet,  885 

Glenard's  disease,  739 
Glioma,  228 
Gliosarcoma,  228 
Gliosis,  228 
Globus  hystericus,  660 
Glossitis,  643 

acute  parenchymatous,  643 
superficial,  643 

chronic  superficial,  643 
syphilitic,  645 
Glossopharyngeal    nerve,    affections    of, 

354 
Glottis,  burns  of,  159 

edema  of,  603 
Glover's  stitch,  140 
Gluteal  artery,  ligation  of,  330 
Glutol,  54 
Glycosuria,  36 

symptoms  after  anesthesia,  36 
Goddard  pessary,  945 
Goiter,  578 

carcinoma  in,  579 

heart,  583 

symptoms,  579 

treatment,  580 

varieties,  578 
form  fruste,  583 
Gonococcus,  885,  107,  44 


1046 


INDEX 


Gonorrhea,  885 

acute  treatment,  887 

chronic  treatment,  888 

complications,  886 

prophylaxis,  887 

U.   S.  military  regulations  in   treat- 
ment, 887 
Gonorrheal  arthritis,  479,  886 

conjunctivitis,  886 

cystitis,  886 

epididymitis,  886 

iritis,  886 

proctitis,  886 

rheumatism,  479,  433 

rhinitis,  886 

sclerotitis,  886 

serum,  479 

synovitis,  477 

tenosynovitis,  365 

urethritis,  885 
Gooch's  flexible  wooden  splints,  381 
Goodell's  speculum,  919 

uterine  dilator,  932 
Gouty  arthritis,  487 

deposits  in  bursas,  373 

neuritis,  342 
Graduated  compress,  311 
Grafting,  bone,  436 

free  fat  transplantation,  263 

mucous  membrane,  263 

nerve,  348 

skin,  260 

Mangoldt's,  263 
pedunculated  flap,  257 
Reverdin's,  262 
Thiersch,  260 
Wolf's,  260 

tendon, 370 
Granny  knot,  142 
Granulation  tissue,  102 

exuberant,  103 
Gravel,  856 
Graves'  disease,  582 
Great  sciatic  nerve,  affections  of,  360 
Greenish  discoloration,  in  diagnosis,  6 
Greenstick  fracture,  374 
Grey's  salt  sac  drain,  152 
Gritti's       supracondyloid       amputation, 

1021 
Grossich  method  of  disinfection,  66 
Growth  of  tumors,  237 
Guillotine,  1006 
Gum  boil,  648 

Gumma,  199,  see  also  special  regions 
Gummata,  tuberculous,  250 


Gummatous  arthritis,  480 

degeneration,  199 

osteomyelitis,  439 

synovitis,  480 
Gums,  epithelioma  of,  650 
Gun  powder  stains,  146 
Gunshot  fracture,  375,  381 

wounds,  144 
Gutta-percha,  uses  of,  in  bone  cavities, 

436 
Gutter  fracture,  516 
Gynecomazia,  622 

Habit,  in  diagnosis,  4 
Hahn's  tracheotomy  tube,  607 
Hallux  rigidus  (H.  flexus),  998 

valgus,  997 
Halstead's  operation  for  amputation  of 
breast,  628 

subcuticular  stitch,  141 

suture,  intestinal,  754 
Hammer  nose,  586 

toe,  998 
Hammond's    wire    splint    for  fracture  of 

lower  jaw,  389 
Hanche  a  ressort,  988 
Hand,  amputation  of,  1008 

deformities  of,  977 

ulcerating  gumma,  199 
Handkerchief  bandages,  78 

for  lower  extremities,  88 

for  suspending  breast,  86 

for  upper  extremities,  83 
Handley,  treatment  of  lymphedema,  336 
Hands,  sterilization  of,  64 
Haptophore,  49 
Hard  corns,  248 
Hardening  in  tumors,  241 
Hare-lip,  634 
Harrison's  sulcus,  441 
Hartley-Krause  operation  for  removal  of 

Gasserian  ganglion,  352 
Hartman's  operation  for  gastrostomy,  707 
Head,  500,  see  fractures  of  skull 

injuries  of  brain,  cerebral 
Healing  of  wounds,  see  repair 
Heart,  compression  of,  273 

concussion  of,  273,  610 

fetal  sounds  in  diagnosis,  9 

massage  of,  274,  34 

overdistension,  272 

wounds  of,  272 
diagnosis,  273 
symptoms,  272 
treatment,  274 


INDEX 


1047 


Heat  in  hemorrhage,  310 

inllammation,  99,  94 

treatment  of  inflammation,  99 
Hebcrden's  nodes,  488 
Hectic  fever,  113,  167 

flush,  113 
Hedonal  in  anesthesia,  28 
Hegar's  operation  for  laceration  of   peri- 
neum, 926 
Height,  in  diagnosis,  10 
Heineke-Mikulicz    operation    of     pyloro- 
plasty, 725 
Helioalpintherapy,  211 
Heliotherapy  in  tuberculosis,  211 
Hemangioendothelioma,  230 
Hemangioma,  226 
Hemarthrosis,  490 
Hematemesis,  694 
Hematocele,  pelvic,  972 

of  cord,  806 

scrotal,  912 
Hematocolpos,  923 
Hematogenous  jaundice,  168 
Hematoma,  138 

arterial,  293 

of  abdominal  walls,  670 

of  dura  mater,  529 

of  ear,  566 

of  scalp,  500 
Hematometra,  923,  931,  970 
Hematomyelia,  551 
Hematorrhachis,  551 
Hematosalpinx,  923,  958 
Hematuria,  846,  268 

essential,  850 
Hemianopsia,  506 
Hemiglossitis,  643 
Hemoglobin,  12 
Hemoglobinuria,  846 
Hemolysis,  14 
Hemolytic  jaundice,  798 

tests,  14 
Hemopericardium,  275 
Hemophilia,  318,  850 

joints  in,  490 
Hemopneumothorax,  611 
Hemoptysis,  694,  610 
Hemorrhage,  306 

bandage  for,  80 

constitutional  symptoms,  307 

diagnosis,  309 
from  shock,  164 

natural  arrest,  308 

resume,  317 

see  special  regions 


Hemorrhage,  treatment,  310 
acupressure,  313 
cold,  310 
compression,  311 
elevation,  310 
forcipressure,  314 
heat,  310 
ligation,  314 
styptics,  310 

suture  of  blood  vessels,  315 
torsion,  314 
varieties,  306 
Hemorrhagic  diathesis,  318 

effusion  in  pericardium,  275 
fever,  308 
infarct,  268 
inflammation,  93 
Hemorrhoids,  834 
external,  835 

treatment  of,  835 
internal,  835 

treatment  of,  835 
Hemostasis,  308,  139 

varieties,  308,  309 
Hemostatic  forceps,  314 
Hemostatics,  311 
Hemothorax,  307 
Henderson,  respiratory  failure,  53 
Hepatic  abscess,  774 
colic,  668,  788 
cysts,  787 
duct,  stone  in,  788 
Hepaticocholangioenterostomy,  792 
Hepaticotomy,  792 
Hepatopexy,  776 
Hepatoptosis,  776 
Hepatotomy,  775 
Hereditary  syphilis,  206,  191 
Hermaphrodism,  921 
Hernia,  799,  see  also  special  regions 
accidents  of,  820 
appendix  in,  801 
bladder  in,  801,  811 
causes  of,  799 
cecum  in,  801 
cerebri,  523 
contents  of,  801 
coverings  of,  801 
en  bissac,  805 
foreign  bodies  in,  801 
hour-glass  sac,  799 
hydrocele  of  sac,  799 
incarceration  of,  820 
inflammation  of,  820 
intestine  in,  801 


1048 


INDEX 


Hernia,  irreducible,  820 

mouth  of,  799 

obstructed,  820 

sac  of,  799 

signs  of,  802,  805 

sliding,  801 

special,  802 

strangulated,  821 

complications  after  taxis  for,  821 
operative  treatment  of,  see  special 

regions 
signs  and  symptoms  of,  823 
taxis  in,  821 

stretching  in,  105 

structure  of,  799 

traumatic,  800 

treatment  of,  802,  see  special  regions 

varieties  of,  802 
Herniotomy,  823 
Herpes,  gangrenous,  248 

labialis,  637 
Herpetic  ulceration,  195 
Herpetiform  syphilide,  197 
Hesselbach's  triangle,  804 
Hexamethyl  violet,  55 
Hexamethyleamin,  66,  507 
Hey's  amputation,  1015 
Hiccough,  34 
Hilton's    method    of    opening    abscesses, 

III,  575 
Hind  gut,  826 
Hip,  ankylosis  of,  485 

diagnosis  of  injuries  about,  416 
disease,  483 

diagnosis  from  sacroiliac  disease,  483 
dislocation  of,  congenital,  453 

traumatic,  455 
effusion  into,  476 
excision  of,  497 
varieties  of,  466,  467,  468 
Hip-joint,  amputation  at,  1023 
anterior  incision  of,  497 
disease,  483 
osteoarthritis  of,  489 
tuberculous  disease  of,  483 
Hippocratic  face,  1 1 
Hirschsprung's  disease,  734 
History  in  diagnosis,  4 

of  tumors,  235 
Hodgen's  splint,  418 
Hodgkin's  disease,  339,  14 
Hoffa's  operation  for  congenital  displace- 
ment of  hip,  454 
Hoffmeister's  method  of  sterilizing  catgut, 
60,  61 


Hollow  foot,  996 

Hopkin's  dressing  for  fractured  patella, 

422 
Horn,  249 

sebaceous,  254 
Horse  hair,  62 

probang,  660 
shoe  kidney,  844 
Horsley's  cyrtometer,  503 
dural  separators,  508 
operation  for  the  removal  of  the  Gas- 

serian  ganglion,  353 
wax,  510 
Hot  air  apparatus,  99 
Hottentot  apron,  921 
Hour  glass  stomach,  695 

hernia,  799 
Housemaid's  knee,  373 
Howard  method  of  artificial  respiration, 

34 
Howship's  lacunas,  438 
Hudson's  burrs,  508 

modification  of  the  DeVilbiss  forceps, 
509 
Hull's  paraffin  treatment  of  burns,  157 
Humerus,  dislocation  of,  459 
condyles,  404 
fractures  of,  395 

anatomical  neck,  395 
treatment,  397 
head, 398 

intercondyloid,  403 
lower  extremity,  400 
separation  of  epiphysis,  lower,  404 

upper,  398 
shaft,  399 

supracondyloid,  400,  401 
surgical  neck,  397 
triangle  splint,  397 
tuberosities,  398 
Hunter's  canal,  ligation  of  femoral  artery 

in,  331 

operation    for    aneurysm,    302 
Hunterian  chancre,  193 
Huntington's  operation  for  transplanting 

bone,  450 
Hutchinson's  teeth,  207 
Hydatid  cysts,  233,  see  also  special  regions 

disease,  7 

moles,  225 

of  Morgagni,  966 
Hydrargyrism,  202 

Hydrarthrosis,  477,  see  hydrops  articuli 
Hydrocele,  909,  see  also  special  regions 

bilocular,  911 


INDEX 


1049 


Hydrocele,  chylous,  912 

congenital,  911,  805 

encysted,  of  cord,  911,  806 
testis,  911,  806 

i<liopathic,  909 

infantile,  911 

inguinal,  91 1 

of  hernial  sac,  799 

of  neck,  571 

tapping,  method  of,  910 

treatment  of,  910 

vaginal,  909 

varieties  of,  909 
Hydrocephalus,  525 

varieties,  525 
Hydroencephalocele,  525 
Hydrogen  peroxid,  54 

neutralized  bj^  54 
Hydrometra,  931 
H^-dronephrosis,  850 
Hydrophobia,  182,  180,  46,  50 

symptoms,  in  dog,  183 
in  man,  184 

treatment,  184 

Pasteur,  185 

Hydrops  antri,  599 

articuli,  477 

cystidis  felleae,  780 

folliculorum,  966 

of  appendix,  767 

of  frontal  sinus,  596 

tubse  profluens,  958 
Hydrosalpinx,  958 
Hygroma,  571,  227 
Hyoid  bone,  fracture  of,  390 
Hyoscin  in  anesthesia,  31 
Hj-perchlorhydria,  689 
Hj-percholesterinemia,  782 
H>'peremia,  95 

reduction  of,  95 
Hyperkeratosis  linguae,  644 
Hypernephroma,  231 
Hyperpituitarism,  443,  437 
Hyperplastic  ovaritis,  964 
Hypertrichosis,   Rontgen   rays   in    treat- 
ment of,  18 
Hypertrophic  osteoarthropathy,  431 
Hj'pertrophied  scar,  105 
Hypertrophy,  see  special  regions 
H\-pochlorus  acid,  56 
H\'podermoclysis,  288 
H>T>oglossal  nerve,  injuries  of,  354 
Hypomycetes,  51 
H^-pophysis  cerebri,  537 
Hypopituitarism,  537 


Hypospadias,  883 

balanitic,  883 

penile,  883 

peroneal,  883 
Hysterectomy,  abdominal,  950,  949 

vaginal,  949 
Hysteria,  180, 

in  spinal  injuries,  547 
Hysterical  edema,  7 

joints,  490 
Hysteroneurasthenia,  547 
Hysteropexy,  942 

Ichthyol  in  inflammation,  98 
Ichthyosis  lingu3e,  643 
Icterus,  see  jaundice 
Idiocy,  577 
Idiopathic  aneurysm,  296 

dilatation  of  the  colon,  734 

epilepsy,  537 

erysipelas,  175 

fragilitas  ossium,  442 

hydrocele,  909 

hydrocephalous,  525 

inflammation,  93 

multiple  hemorrhagic  sarcoma,  253 

tetanus,  178 
Ileosigmoidostomy,  764 
Ileostomy,  755 
Ileus,  740 
Iliac  colostomy,  755 

veins,  inflammation  of,  278 

vessels,    ligation    of,    see    common, 
external  and  internal 
Iliopectineal  bursa,  373 
Iliopsoas,  373 
Ilium,  fractures  of,  410 
Immobility  in  tumor  diagnosis,  240 
Immune  bodies,  49 

serums,  49 
Immunity,  48,  47 

Colics',  192 

Profeta's,  192 
Impacted  calculus,  in  ureter,  857 

cerumen,  566 

embolus,  267 

feces,  749 

fracture,  374 

urethral  calculus,  885 
Impaction  of  foreign  bodies  in  bowel,  748 
Impassable  stricture,  of  urethra,  893 
Imperforate  anus,  826 
Impermeable  stricture  of  urethra,  893 
Impetigo,  syphilitic,  197 
Implantation  dermoids,  233 


io;o 


INDEX 


Impotence,  901 
Impression  fracture,  515 
Incarcerated  hernia,  820 
Incised  wounds,  142 
Incision,  exploratory,  6 
Incisions,  relaxation,  256 

technic  in,  6q 
Incomplete  dislocation,  455 

fracture,  374 

inguinal  hernia,  802 
Incontinence  of  urine,  869 

retention,  870,  916 
Indian  method  of  complete  rhinoplasty, 

589 
Indifferent  tissue,  92 
Indirect  fracture,  375 

gangrene,  127 

inguinal  hernia,  802 
congenital,  803 
Induced  thrombus,  266 
Induration,  foliaceous,  193 

nodular,  193 

parchment,  193 
Infantile  arthritis,  432 

hydrocele,  911 

inguinal  hernia,  804 

palsy,  484,  2,  564 

scurvy,  433,  441 

sv'philis,  206 

umbilical  hernia,  814 

uterus,  930 
Infarct,  268 
Infection,  42 

determining  factors,  47 

extends,  46 

increased  susceptibilitj-,  47 
Infections,  prevented  by,  49 
Infectious  leukocytosis,  13 
Infective  arthritis,  479 

inflammation,  93 

osteomyelitis,  acute,  see  osteomyelitis 

phlebitis,  277 

thrombophlebitis,  277 

thrombosis  of  cerebral  sinuses,  529, 

thrombus,  266 
Inferior  dental  nerve,  operations  on,  352 

maxilla,  see  lower  jaw 

maxillary  nerve,  operations  on,  352 

thjToid  artery,  compression  of,  313 
ligation  of,  326,  580 
Inflamed  hernia,  820 
Inflammation,  91,  see  also  special  regions 

absorption  in,  97 

causes  of,  91,  see  also  susceptibility, 
47 


Inflammation,  cellulitis,  176 

constitutional  treatment,  loi 

extends  (infection  Chapter  III) 

extension  of,  46 

exudation  in,  91 

non-vascular  tissue,  92 

pathology,  92 

symptoms  of,  93 

termination  of,  93 

tissue  changes,  92 

treatment  of,  95 
Bier's,  97,  211,  112 

varieties  of,  93 

vascular  changes  in,  91,  92 
Infraction,  374 

Infraorbital  nerve,  operation  on,  351 
Infrapatellar  bursa,  373 
Infusion  of  salt  solution,  287 
Ingrowing  toe  nail,  255 
Inguinal  adenitis,  338 

bubo,  193,  338,  897 

colostomy,  756 

hernia,  802 

diagnosis  of,  805 
treatment  of,  806,  807 
variations  in  operations  for,  810 
varieties  of,  802 

hydrocele,  911 

perineal  hernia,  817 
Inhaler,  Esmarch,  29 
Inhalers  in  anesthesia,  24 
Inherited  s\'philis,  206 

bone  affections  in,  438,  207 
Injections  for  cure  of  aneurysm,  302 

in  gonorrhea,  888 

intramuscular,  in  syphilis,  201 

of  hydrocele,  911 
Injuries,  see  special  regions 

in  diagnosis,  4 
Innominate  artery,  ligature  of,  320 
Inoperable  carcinoma,  219 

malignant     disease,     treatment     of, 
219,  231 
tumor,  18 

sarcomata,  231 
Insanity,  538,  36,  174 
Insect  bites  and  stings,  153 
Inspection,  in  diagnosis,  5 
Instruments,   preparation  of,   for   opera- 
tions, 59 
Insufflation  of  ether,  25,  26,  27 
Intelligence,  center  of,  506 
Interacinous  cysts  of  breast,  633 
Intercondyloid  T-fracture,  403 
Intercostal  artery,  hemorrhage  from,  610 


INDEX 


io;i 


Interdental  splints,  389 
Interilio-abdominal  amputation,  1024 
Intermaxilla.  in  hare-lip,  634 
Intermediate  hemorrhage,  307 

syphilis.  191 
Intermuscular  lipomata,  222 
Internal  anthrax,  186 

carotid  artery,  hemorrhage  from,  567 

derangement  of  knee  joint,  471 

epicondyle,  fracture,  403 
ligation  of,  t,22 
wounds  of,  521 

hemorrhage,  307 

hernia.  817 

iliac  artery,  ligation  of,  330 

jugular  vein,  hemorrhage  from,  567 

mammary  arterj',  hemorrhage  from, 
610 
ligation  of,  326 

popliteal  nerve,  affections  of,  361 

pudic  arter\',  ligation  of,  330 

urethrotomy,  893 
Interpretation  of  X-ray  pictures,  15,  16 
Interscapulothoracic    amputation,    1002, 

1014 
Intersigmoid  fossa,  hernia  into,  820 
Interstitial  appendicitis,  766 

cholecystitis.  780 

hernia,  inguinal,  804 

inflammation,  93 

keratitis.  207 

mastitis,  623 
Intestinal  adhesions.  744 

anastomosis,  760 

bands,  744 

diverticula,  733 

exclusion,  764 

fistula,  758 

localization,  753 

obstruction,  823,  740,  68 
chronic,  743 
subacute,  743 

paralysis,  752 

polyps,  749 

ptosis,  739 

sutures,  760 

worms,  748 
Intestines,  affections  of,  732 

anastomosis  of,  760 

carcinoma  of,  747 

congenital  malformations  of,  733 

enteroptosis,  739 

exclusion  of,  764 

foreign  bodies  in,  748 

gangrene  of,  823,  686 


Intestines,  intussusception,  750 
acute,  75: 
chronic.  751 

lateral  implantation  of,  764 

operations  on,  753 

perforation  of,  typhoid,  737 

rupture  of,  671 

segregation  of,  764 

stenosis,  733 

stricture  of,  746 
cicatricial,  746 
neoplastic,  746 
spasmodic,  748 

tuberculosis  of,  738 

tumors  of,  746,  749 

volvulus  of,  745 

wounds  of,  670 
Intraabdominal  gauze  pads,  62 

inflammation,  14 

shortening  of  round  ligaments,  943 
Intraarticular  ankylosis,  491 

fracture,  374 
Intracanalicular  fibroma.  625 
Intracapsular  fracture  of  femur,  412 

humerus,  397 
Intracranial  abscesses,  532,  570,  see  also 
cerebral,  head,  skull,  brain 

blood  vessels,  injuries  of.  520 

complications  of  otitis  media,  567 

hemorrhage,  519,  514 

in  the  new-bom,  521 

inflammation,  529 

tumors,    534,    see    also    head,    skull, 
brain,  cerebral 
Intrailiac  hernia,  805 
Intramammar>'  abscess,  622 
Intramedullary     hemorrhage     of     spinal 

cord.  551 
Intraparietal  hernia,  804 

sulcus,  503 
Intraperitoneal  abscess.  684 
IntrapharjTigeal  insufHation  of  ether,  26 
Intraspinal  hemorrhage,  551 

tumor,  564 
Intratracheal  insuflBation  of  ether,  34,  26 
Intrauterine  fractures.  375 
Intravenous  etherization.  28 

infusion,  287 
Intraventricular  injection,  528 
Intubation  of  lar>Tix,  608 
Intussusception,  750 

congenital,  733 

varieties  of,  750 
Intussusceptum,  750 
Intussuscipiens,  750 


I0^2 


INDEX 


Inunction  of  mercury,  201 
Inversion  of  testis,  902 

uterus,  945 
Inveterate  headache,  538 
Involucrum,  435 

Involuntary  seminal  emissions,  900 
Involution  cysts,  633 
Inward  dislocation  of  hip,  468 
lodin,  tincture  of,  54,  66 
Iodoform,  55 

emulsion,  114,  55,  481 

gauze,  63 

poisoning,  55 
lodophilia,  13 
Iritis,  198,  886 
Iron  wire,  62 
Irradiation,  517 
Irreducible  swellings,  806 

hernia,  806,  820 
Irrigation,  constant,  177 

of  chronic  abscesses,  112 
Irritants,  100 
Ischemia,  47 

see  trench  foot,  160 
Ischiorectal  abscess,  830,  831 
Island  flaps,  257 
Isopral  in  anesthesia,  28 
Italian  method  of  rhinoplasty,  591 

Jackson's  bronchoscope,  601 

membrane,  735 
Jacksonian  epilepsy,  538 
Jacob's  ulcer,  177 
Janet's  method  of  irrigating  the  urethra, 

888 
Jarisch-Herxheimer  reaction,  204 
Jaundice,  catarrhal,  779 
hematogenous,  168 
recurring,  784 
Jaw,  lower,  cleft  of,  636 
closure  of,  651 
cysts  of,  648 
dislocation  of,  457 
epulis,  649 
excision  of,  650 
fibrocystic  disease  of,  649,  227 
fracture  of,  388 
necrosis  of,  648,  434 
temporary  resection,  650 
tumors  of,  649 
enchondroma,  649 
epithelioma,  650 
epulis,  649 
fibroma,  649 
osteoma,  649 


Jaw,  tumors  of,  sarcoma,  649 
upper,  cysts  of,  648 
epulis,  649 
excision  of,  650 
fracture  of,  388 
necrosis  of,  648 
tumors  of,  649 
see  lower 
Jejunostomy,  754 
Jejunum,  peptic  ulcer  of,  723 
Jiann     operation     for     salivary     fistula, 

642 
Joints,  452 

affections  in  syringomyelia,  489 
ankylosis  of,  491,  493,  494 
aspiration  of,  475 
Charcot's,  489 
diseases  of,  473 

local  examination  in,  474 
dislocations  of,  453 
effusion  into,  evidences  of,  476,  475 
empyema  of,  477 
examination  of,  473 
excision  of,  495 
false,  385 

gonorrheal  affections  of,  479 
gouty,  487 
hemophilic    disease    of,    see    hemar- 

throsis 
hysterical,  490 
incision  of,  475 
infection,  473 
injuries  of,  452 
involvement  of  in  infectious  fevers, 

473,  455 

lipoma  aborescens,  222,  491 

loose  bodies  in,  490,  489 

mice,  490 

neuralgic,  490,  474 

pyemic,  477 

resection,  495 

rheumatic,  487,  488 

ruptured  semilunar  cartilages  in,  471 

sprains  of,  452 

syphilis  of,  480,  198 

tuberculous  disease  of,  482 

wounds  of,  452 
Jones'  cock-up  splint,  408 

position,  403 
Jonnesco's  operation  for  excision  of  the 

cervical  sympathetic,  361 
Jugular  vein,  hemorrhage  from,  567 

ligation  of,  279,  531 
Jumping  hip,  988 
Jury  mast,  Sayre's,  562 


INDFX 


1053 


Kadcr's  gastrostomy,  708 

Kanavel  operation  for  trifacial  neural^'ia, 

351 
Kangaroo  tendon,  62 
Karyokinesis,  102 
Katzenstein's  operation  for  varicose  veins, 

284 
Keen's  double  brain  electrode,  510 

rongeur  forceps,  508 
Keloid,  cicatricial,  220 

false,  253,  220,  105 

spontaneous,  253 

true,  253,  220 
Keratitis,  interstitial,  207 
Keratosis  senilis,  252 
Kemig's  sign,  530 
Keyes-Ultzman  syringe,  889 
Kidneys    and    ureters,    afifections    of. 

843 
abscess  of,  853 
amyloid  disease  of,  112 
blood  examination  in,  846 
calculus,  855 
carcinoma,  861 

congenital  affections  of,  843,  861 
cystic  disease  of,  862 
cysts,  862 
decapsulation,  864 
degenerative  changes,  848 
ectopic,  843 
examination  of,  843 
exploration  of,  844 
floating,  843 

functional  capacity  of,  845 
hematogenous  infection  of,  853 
horse  shoe,  843 
hydronephrosis,  850,  843 
hypernephroma,  861 
injuries  of,  673,  848 
irrigation  of  pelvis  of,  852 
movable,  849 

nephritis,  operation  for,  863 
operations  on,  862 
presence  of  both  kidneys,  846 
pyelitis,  851 
pyelonephritis,  852 
pyonephrosis,  852 
rupture,  673 
sarcoma,  861,  843 
solitary,  843 
surgical,  852 

tuberculous  disease  of,  854 
tumors,  861 
twisting  of  pedicle,  849 
wounds,  848 


Killian's  operation   for  empyema  of  the 

frontal  sinus,  597 
Kimpton   method   of   blood   transfusion, 

286 
Kingsley's  interdental  splint,  390 
Kleb's  tuberculocidin,  213 
Klumpke  paralysis,  355 
Knee-chest  posture,  940 
Knee-joint,  amputation  through,  102 1 

ankylosis  of,  491 

dislocation  of,  469,  471 

effusion  into,  476 

erasion  of,  486 

excision  of,  498,  489,  486 

gonorrheal  infection  of,  479 

housemaid's,  373 

incisions  for  drainage,  476 

internal  derangement  of,  471 

semilunar  cartilage,  dislocation  of .  471 

tuberculous  disease  of,  486 
Knock-knee,  989 
Knots,  142 
Knotted  bandage,  80 
Kobelt's  tubes,  cysts  of,  232,  967 
Koch's  postulates,  45 

tuberculin,  212 
Kocher's   method  of  gastroenterostomy, 

713 
method  of  treating  dislocation  of  the 

humerus,  460 
operation  of  pylorectomy,  728 
for  excision  of  the  hip,  497 
for  removal  of  the  tongue,  647 
temporary  resection  of  upper  jaws 
for      exposing      nasopharyngeal 
growths,  650 
Kondoleon's  operation  for  lymphedema, 

337 

Kraske's  method  of  excision  of  rectum, 
841 

Kraurosis  vulvae,  922 

Kraus  normal  bovine  serum,  187 

Kroelein  method  in  pylorectomy,  728 

Kronlein's  method  of  craniocerebral  to- 
pography, 504 

Kuettner's  infusion  of  salt  solution  with 
oxygen,  288 

Kummel's  anesthesia,  28 

Kussmaul's  sign,  277 

Kjrphosis,  556 

Labial  abscess,  922 

artery,  compression  of,  313 
chancre,  195 
hernia,  803 


I054 


INDEX 


Laborde's  method  of  artificial  respiration, 

34 
Labyrinth,  suppuration  of,  567 
Lacerated  wounds,  143 
Laceration,  see  special  regions 
Lachrymal  bone,  fracture  of,  387 
Lacteal  cysts,  633 
Lacunar  abscess,  109 

Lambotte's  apparatus  for  fixation  of  frac- 
tures, 383 
Laminae,  fracture  of,  see  spine 
Laminectomy,  544,  551 
Lancereaux  treatment  of  aneurysm,  300 
Lane's  forceps,  382 

kink,  703 

operative  treatment  of  fractures,  382 

plate  for  fracture,  383 
Langenbeck's    operation    of    excision    of 
ankle,  497 
elbow,  496 
hip.  497 

incision  of  wrist,  496 

on  nose,  586 
Laparotomy,  666 
Lardaceous  disease,  113 
Larrey's   amputation   at   shoulder   joint, 

1014 
Laryngeal  cartilage,  fracture  of,  390 

crises,  600 

stenosis,  600 
Laryngectomy,  605 
Laryngismus  stridulus,  600 
Laryngitis,  edematous,  603 
Laryngocele,  571 
Laryngoscope,  599,  6 
Laryngotomy,  606 
Laryngotracheotomy,  606 
Larj'nx,  abscess  of,  603 

acute  edema  of,  603,  see  also  edema 
of  glottis,  603 

artificial,  605 

chondritis,  603 

congenital  fissures,  571,  599 
fistulae,  571,  599 

diseases  of,  599,  571 

epithelioma  of,  604 

foreign  bodies  in,  599 

fractures  of,  389,  600 

gumma  of,  604 

injuries  of,  604 

intubation  of,  608 

papilloma  of,  604 

paralysis  of,  355,  604 

stenosis  of,  600 

syphilis  of,  603 


Larynx,  tuberculous  disease  of,  604 

tumors  of,  604 

ulceration  of,  600 
Lateral  anastomosis  of  intestine,  763 

curvature  of  spine,  554 
in  hip  disease,  483 

flap  amputation,  1005 

implantation  of  intestine,  764 

ligature,  315 

lithotomy,  880 

sinus,  drainage  of,  532,  278 
hemorrhage  from,  567 
thrombophlebitis  of,  531,  168 
thrombosis,  534 

ventral  hernia,  816 

ventricle,  puncture  of,  528,  529 
Lavage  of  stomach,  706,  71 
Lawn-tennis  arm,  362 
Lead  poisoning,  535 
Lead-water  and  laudanum,  97 
Leaking  aneurysm,  298,  694 
Leather-bottle  stomach,  704 
Lee's  solution  for  burns,  158 

technic,  58 
Leech,  artificial,  96,  568 
Leeching,  96 
Le  Fort's  amputation  at  the  ankle  joint, 

1017 
Leg,  amputation  of,  1017 

Barbadoes,  336 

fracture  of  both  bones,  428,  429 
Leiomyoma,  225 
Leiter's  tubes,  97 
Lembert's  intestinal  suture,  754 
Lenticular  carcinoma,  252 

papules,  197 
Leontiasis  leprosa,  190 

ossea,  443,  225 
Lepra,  190 

mutilans,  190 
Leprosy,  190 
Leptomeningitis,  529 

acute,  530,  563 

chronic,  530,  563 
Leptothrix,  see  bacteria 
Leukemia,  12,  306 

IjTnphatic,  340 
Leukemic  tumors,  253,  229 
Leukocytes,  enumeration  of,  13 

migration  of,  in  inflammation,  92  , 

phagocytic  action,  45 
Leukocytosis,  339,  169,  166,  92,  45,  13,  12 

in  abscess,  109 

infectious,  13 

noninfectious,  12 


INDEX 


lO 


:)D 


Leukopenia,  14 
Leukoplakia,  253.  O43,  5 
Levis  apparatus  for  reduction  of  disloca- 
tion of  phalanges,  465 

splint.  407 
Lewisohn  method  blood  transfusion,  287 
Ligation  of  arteries,  effects  of,  315 

for  aneurysm,  301 
epilepsy,  537 
gangrene  following,  132 
hemorrhage,  314 
malignant  growths,  219 
trigeminal  neuralgia,  350 

in  continuity,  319 

technic  for,  319 
Ligatures,  60 

types,  314 
Light,  electric,  6 
Lightning  stroke,  161 
Linear  discoloration,  in  diagnosis,  6 

excision  for  hemorrhoids,  836 
Lingual  arter\-,  ligature  of,  323 

goiter,  576 

nerve,  operation  on,  352 
Linnitus  aurium,  307 
Lipoma,  221 

arborescens,  222,  491 

diffuse,  222 

fibrolipoma,  222 

intermuscular,  222 

nevolipoma,  222 

subcutaneous,  222 

subfacial,  222 

submucous,  222 

subserous,  222 
Lips,  affections  of,  634 

chancre  of,  194,  637 

cleft  of,  636 

cysts  of,  638 

epithelioma  of,  638,  217,  251 

horns  of,  636 

strumous,  638 

warts  of,  625 
Liquefaction  of  thrombus,  266 
Liquid  air,  37 

Lisfranc's  amputation  of  foot,  1015 
Lister's  modified  flap  and  circular  ampu- 
tation, 1 006 
Litholapaxy,  878 
Lithopedion,  962 
Lithotomy,  lateral,  880 

median,  880 

perineal,  880 

position.  880 

suprapubic,  879 


Lithotrites,  878 

Litten  phenomena,  686 

Little's  disease,  521 

Littre's  hernia,  801 

Littre-Maydl  operation  of  colostomy,  756 

Liver,  abscess  of,  774 

affections  of,  774 

cirrhosis  of,  3,  777 

cysts  of,  775 

hemorrhage  from,  672 

hydatid  cysts,  775 

injuries,  672 

laceration  of,  672 

see  also  hepatic 

tumors  of,  776 
Lobar  mastitis,  623 
Lobular  mastitis,  623 
Local  anesthesia,  see  anesthesia 

anesthetics,  method  of  injection,  38 

examination  in  diagnosis  of  tumors, 
244 

shock,  163 
Locality,  in  diagnosis,  2 
Localization,  in  cerebral  injuries,  502 

intestinal,  753 

of  foreign  bodies  b}'  the  X-ray,  1 7 

spinal,  539 
Lock  jaw,  180,  178 
Locomotor  ataxia,  489,  116,  8,  115 
Longitudinal  fissure,  502 

fracture,  374 
Loose  bodies  in  joints,  490 

knees,  990 
Lordosis,  557 
Lorenz's   method   of   treating   congenital 

dislocation  of  hip,  454 
Lowenberg's  forceps,  596 
Lower  jaw,  see  jaw 
Lowman's    plate-holding    apparatus    for 

fractures,  383 
Lucas-Championiere  on  fracture,  381 
Ludloff's  sign,  416 
Ludwig's  angina,  575 
Lues,  204 
Lumbago,  483 
Lumbar  abscess,  559 

caries,  558 

colostomy,  757 

disease,  554,  555,  556 

hernia.  817 

incision  for  exposing  kidney,  862 

plexus,  injury  of,  359 

puncture,  544,  517,  528 
Lumpy- jaw,  188 
Lungs,  abscess  of,  613,  611,  619 


1056 


INDEX 


Lungs,  cysts  of,  619 

decortication  of,  617 

discission  of,  617 

foreign  bodies  in,  599,  610 

gangrene,  618 

hemorrhage  from,  610 

hernia  of,  6n 

operations  upon,  617 

prolapse  of,  611 

rupture  of,  610 

stones,  599 

tuberculosis,  operation  for,  618 

wounds,  610 
Lupoid  ulcer,  250,  118 
Lupoma,  250 
Lupus,  250,  644 

erythematosus,  251 

exedens,  250 

exfoliativus,  250 

exulcerans,  250 

hypertrophicus,  250 

treatment  of,  by  Finsen  light.  251 
X-rays,  251 

vulgaris,  251,  250 
Luschka's  tonsil,  595 
Luxatio  erecta,  459 
Luxation  of  joints,  453 
Lymphadenitis,  acute,  337 

chronic,  338 

syphilitic,  339,  196 

tuberculous,  338 
Lymphadenoma,  227,  338 
Lymphadenosis,  general,  339 
Lymphangiectasis,  335,  227 
Lymphangioendothelioma,  341,  230 
Lymphangioma,  227,  337 
Lymphangitis,  337,  6 

acute,  337 

chronic,  337 
Lymphatic  edema,  336 

fistula,  336 

glands,  affections  of,  340 

secondary  growths  in,  see  sarcoma 

and  carcinoma 
simulating  hernia,  806 
syphilis  of,  339,  196 
tuberculosis  of,  338 

leukemia,  340 

malignancy,  340 

nevus,  226,  335 

system,  335 

varix,  336 

vessels,  diseases  of,  335 

warts,  336 
Lymphatism,  341 


Lymphedema,  336,  227 
Lymphocytoma,  340 
Lymphoma,  227,  338 
Lymphorrhea,  335 
Lymphosarcoma,  229,  340 
Lysins,  48 
Lysol,  54 
Lyssa,  182 
Lyssophobia,  185  ( 

McBurney's    operation   for   appendicitis, 

771 

point,  768 
McGraw's  elastic  ligature,  717 
Mclntyre  splint,  418 
McWilliams  bone  transplantation,  499 
Macewen's  operation  for  knock-knee  (os- 
teotomy), 990 

treatment  of  aneurysm,  301 

triangle,  569 
Mackensie's  operation  for  fistulae  in  ano, 

834 
Macrocheilia,  637,  227,  335 
Macrodactylia,  979,  443 
Macroglossia,  643,  227,  335 
Macrostoma,  636 
Macrotia,  566 
Madelung's  deformity,  978 
Magnet  for  the  removal  of  iron  bodies,  602 
Mahler's  symptom,  278 
Maisonneuve's  urethrotome,  894 
Makkas'  operation  for  filling  bone  cavities, 

437 
Malachite  green,  55 
Malar,  fracture  of,  387 
Malaria,  13,  51,  170 
Male  genital  organs,  882 
Malignant  cysts  of  neck,  572 

dermatitis,  620 

edema,  134 

epulis,  649 

goiter,  577 

pustule,  185 

tumors,  214 

ulcers,  116 
Mallein,  188 

Malleolo-phalangeal  bandage,  88 
Malleolus,  ligation  behind,  :iss 
Mallet  finger,  980 
Malleus,  187 
Mai  perforant,  999 
Malpositions  of  testis,  902 
Malum  senile,  488 
Mamma,  see  breast 
Mammilitis,  620,  622 


INDEX 


1057 


^landiblc,  see  lower  jaw 

MaiiKoldt's  method  of  skin  graftiiifj,  263 

Mania  a  potu,  173 

Marie's  disease,  431 

Marjolin's  ulcer,  218,  105 

Marmourian's     operation     for     \aricose 

veins,  283 
Marshall     Hall's     method     for    artificial 

respiration,  :is 
Marsupialization  of  ovarian  cyst,  qyi 
Martin's  canvas  for  reduction  of  fractures, 
382 

mercury  treatment   in   syphilis,    202 

rubber  bandage,  122 

uterine  curette,  936 
Mason's  pin,  387 
Massage,  98 

danger  of,  98 
aneurysm,  98 

in  treatment  of  fractures,  381 

of  inflammation,  98 

of  heart,  274,  34 
Mastitis,  622 

acute,  622 

chronic,  622 

circumscribed,  623 

diffuse,  623 

lobar,  623 

lobular,  623 

interstitial,  623 

suppurative,  623 
Mastodynia,  621 
Mastoid  antrum,  suppuration  in,  568 

disease,  534 
Mastoiditis,  568,  534 
Matas  operation  for  aneurj'sm,  303 

splint  for  fracture  of  lower  jaw,  390, 

391 
test  for  efficiency  of  collateral  circula- 
tion, 1000,  303 
Maunsell's  method  of  end-to-end  anasto- 
mosis, 761 
of  resection  of  the  rectum,  842 
Maxillarj''  nerves,  operation  upon,  352 

sinus,  empyema  of,  597 
Mayo's  end-to-end  anastomosis,  761 
method  of  gastroenterostomy,  726 
operation  for  partial  excision  of  gall- 
bladder, 789 
for  partial  thyroidectomy,  581 
pylorectom)',  728 

transgastric  partial  gastrectomy,  726 
for  umbilical  hernia,  815 
for  varicose  veins,  283 
of  pylorectomy,  724 
67 


Meatotomy,  882 
Mechanic  injuries,  138 
Mechanical  dysmenorrhea,  956 

sterilization,  51 
Meckel's  diverticulum,  733,  677 

ganglion,  351 
Median  cervical  fistula,  571,  572 

hare-lip,  634 

hernia,  816 

lithotomy,  880 

nerve,  affections  of,  357 
Mediastinopericarditis,  277 
Mediastinum  abscess,  619 

tumors,  619 
Mediogastric  resection,  696 
Medulla  of  bone,  inflammation  of,  see  os- 
teomyelitis 
Medullary  carcinoma,  218 

narcosis,  40 

of  breast,  626 
Melanotic  sarcoma,  230 
Melon-seed  bodies,  see  also  rice  bodies, 

365, 372 
Meltzer-Auer  intratracheal  insufflation  of 

ether,  26 
Membrane  grafting,  263 
Membranous  dysmenorrhea,  956,  936 
Meningeal  hemorrhage,  cerebral,  519 

spinal,  551 
Meningitis,  cerebral,  acute,  530,  563 

cerebro-spinal,  epidemic,  530 

spinal,  563 
Meningocele,  524,  552 

spurious,  501 

traumatic,  501 
Meningoencephalitis,  529,  535 
Meningoencephalocele,  see  encephalocele 
Meningomyelocele,  552 
Menorrhagia,  955 
Menstruation,  disorders  of,  954 
Mercurial  inunction,  98 

necrosis  of  jaw,  648,  434 
Mercurialism,  202 

Mercury  in  treatment  of  syphilis,  201 
Mesarteritis,  290 
Mesentery,  affections  of,  672,  686 

cysts,  687 

embolism  of  arteries  of,  687 

thrombosis  of  veins  of,  687 
Mesoblastic  tumors,  220,  215 

innocent,  220 

chondromata,  223 
fibromata,  220 
glioma,  228 
hemangiomata,  226 


I058 


INDEX 


Mesoblastic   tumors,   innocent,  lipomata, 

221 

lymphangiomata,  227 
myxoma,  225 
neuroma,  Chapter  XVII 
odontoma,  227 
osteoma,  225 
malignant  or  sarcomata,  228 
endothelioma,  230 
giant  cell,  230 
hypernephroma,  231 
melanotic,  230 
round  cell,  229 
spindle  cell,  230 
Metacarpal  bones,  dislocations  of,  464 

fractures  of,  410 
Metacarpophalangeal    joint,    amputation 
at,  1009 
dislocation  at,  465 
Metastatic  abscess,  109,  168,  268 
erysipelas,  175 
growths,  243 
inflammation,  93 
Metasyphilis,  200 
Metatarsal  bones,  dislocation  of,  473 

fracture  of,  430 
Metatarsalgia,  996 
Methyl  chlorid,  37 
Metritis,  937 

varieties,  937 
Metrorrhagia,  955,  307 
Metsehnihoff's   prophylaxis   for   syphilis, 

201 
Michel  clamps,  140 
Microbic  gangrene,  134,  127 
Microcephalus,  529 
Micrococcus  tetragenus,  107 

pyogenes  tenuis,  107 
Micromazia,  620 
Micromelia,  442 
Microstoma,  636 
Microtia,  566 

Middle-ear  disease,  see  otitis  media 
Middle    meningeal    artery,    hemorrhage 

from,  519,  520,  567 
Midtarsal  joint,  amputation  through,  1016 
Mikulicz-Hartmann  line,  728 
Mikulicz's  disease,  640 
drain,  71 
law,  12 

operation  for  torticollis,  574 
Miliary  tubercle,  208 

tuberculosis,  210,  567 
Military  wounds,  146 
Milk  fistulc-e,  622 


Milk  leg,  277 

Milzbrand,  185 

Miner's  elbow,  373 

Mirault's  operation  for  hare-lip,  636 

Mitosis,  102 

Mixed  chancre,  193 

infection,  45 

parotid  tumor,  641 

thrombus,  265 

treatment  of  syphilis,  203 

tumors,  215,  230 
Mobility  in  diagnosis,  9 

of  tumors,  239 
Moebius's  sign,  583 
IMoeller-Barlow  disease,  441 
Moist  gangrene,  126 

heat,  51 
Mole,  249,  s 

lipomatodes,  249 

pigmentosus,  249 

pilosus,  249 

spilus,  249 

verrucosus,  249 
Mollities  ossium,  443 
Molluscum  contagiosum,  51 

fibrosum,  220,  344 
Monococci,  42 

Monod  and  Vanvert's  method  for  tendon 
lengthening,  369 

for  tendon  shortening,  371 
Monoplegia,  506 
Monsel's  solution,  226,  302 
Montgomery  method   of   shortening   the 

round  ligaments,  943 
Moore's   method  of   treatment   of   aneu- 
rysm, 301 
Moore-Corradi    treatment   of   aneurysm, 

301 
Moorhof's  wax,  437 
Morbus  coxae,  483 

senilis,  489 
jMorcellement  of  uterus,  950 
Morgagni,  hydatid  of,  cysts  from,  966 
Moriarty's  splint  for  fracture  of  jaw,  389, 
Morison's  bip,  151 
Mormorek's  serum,  176 
Morning  diarrhea,  840 
Moro's  tuberculin  test,  211 
Morphea,  253 

Morphin,  injection  hypodermic,  in  anes- 
thesia, 30 

objections  to  administering,  31 
Mortification,  126 
Morton's  disease,  996 

fluid,  552,  528 


INDEX 


1059 


Morton's     opcralion     for     transplanting 

bone,  450 
Moschcowitz's  operation  in    prolapse  of 
rectum,  838 

osteoplastic  amputation  of  leg,  1018 
Moss'   division  of  individuals    by  blood 

groups,  285 
Moszkowitz  test  for  gangrene,  1000,  128 
-Mother's  mark,  226 
Motion,  absence  of,  in  diagnosis,  6 
Motor  aphasia,  506 

area,  topography  of,  505 

oculi  nerve,  afifections  of,  349 
Mouth,  affections  of,  647 

burns  of,  159 

chancre  of,  195 

sterilization  of,  65,  67 
Movable  kidney,  849 

spleen,  797 
Moynihan's  treatment  of  gastric  ulcer,  692 
Mucocele  of  appendix,  767 

of  frontal  sinus,  596 
Mucous  patches,  198 

fistula,  678 

polypi,  594 
Miiller's  law,  214 
Multiple  fracture,  374 

neuritis,  342 

neurofibromata,  344 
Mummification,  126 
IMumps,  640 
Mural  thrombus,  265 
Murphy's  button,  762 

treatment  of  arthritis,  479 
of  peritonitis,  682 
of  pulmonary  tuberculosis,  618 
Muscles,  affections  of,  362 

carcinoma  of,  365 

contusion  of,  362 

hernia  of,  362 

inflammation  of,  364 

injuries  of,  362 

massage  of,  364 

ossification  of,  364 

reaction  after  nerve  section,  347 

rupture,  362 

strains,  362 

suppuration  of,  364 

tumors  of,  365 
Muscular  excitement  in  anesthesia,  29 
Musculospiral  nerve,  injury  of,  357 
Mycelial  fungi,  X-ray  treatment,  18 
Mycetoma,  189 
Mycosis  fungoides,  229,  253 

see  trench  foot,  160 


Myelocele,  552 
Myeloid  sarcoma,  230 
Myelomata,  230 

primary  multiple,  447 
Myeloplasty  of  Clairmont-Erlich,  461 
Myer,  pneumcctomy  operation,  61 3 
Myoma,  225,  364 

cavernosum,  225 
Myomectomy,  950 
Myopia,  556 
Myositis,  364 

ischemic,  976,  364 

ossificans,  364,  225 
Myxedema,  577,  444,  7 
Myxoma,  225,  364,  444 
Myxter's  operation  on  fifth  nerve,  352 

Nabothian  cyst,  935 
Nails,  affections  of,  255,  198 
Nares,  packing  of,  593 
Nasal  bone,  fracture  of.  386 
cavities,  tumors  of,  594 
feeding,  182 
polypi,  594 
septum,  deviation  of,  592 

fracture  of,  386 
spurs,  592 
Nasofrontal  duct,  catheterization  of,  597 
Nasoorbital  fissure,  636 
Nasopharyngeal  polypus,  594 
Natiform  skull,  207 
Nationality  in  diagnosis,  2 
Neck,  abscess  of,  574 
affections  of,  570 
cellulitis  of,  574 
cysts  of,  571,  604 
acquired,  572 
bursal,  572 

hydatid  (Chapter  XIII) 
malignant,  572 
sebaceous  (ChapterjXIV) 
thyroid,  see  cystic  goiter 
congenital,  571 
blood,  572 
branchial,  571 
lymphangioma,  572 
thyroglossal,  571 
development  of,  570 
fistulas  of,  570 
hydrocele  of,  571 
tuberculous  glands  of,  338 
tumors  of,  341,  570 
Necrosis,  acute,  432,  431,  434,  126 
after  compound  fracture,  378 
fat,  794 


io6o 


INDEX 


Necrosis,  mercurial,  434 

quiet,  435 

syphilitic,  440 

tuberculous,  438 

typhoid,  434 
Needle  wounds,  143 
Negri  bodies,  182 
Nekton's  line,  413 

operation  for  filling  bone  cavities,  437 
Neoarsphenamin,  205 
Neoplasms,  214 
Neosalvarsan,  205 
Nephrectomy,  864,  850 
Nephritis,  operation  for,  864 
Nephrolithiasis,  855 
Nephrolithotomy,  863 
Nephropexy,  863 
Nephroptosis,  849 
Nephrostomy,  864 
Nephrotomy,  863,  851 
Nerve  anastomosis,  347 

grafting,  348 

stretching,  348 

suture,  347 

a  distance,  348 

transplantation,  348 

tubulization,  348 

Nerves,  affections  of,  342 

special,  349 

compression  of,  345 

contusions  of,  345 

degeneration  of,  346 

inflammation  of,  342 

injuries  of,  344 

partial  section  of  mixed,  349 

regeneration  of,  347 

rupture  of,  345 

changes  following,  346 

see  also  the  special  nerves 

suture  of,  349 

tumors  of,  343 
Nervous  system,  syphilis  of,  200 
Nervousness,  postoperative,  72 
Neuber's  operation  for  filling  bone  cavi- 
ties, 437 
Neuralgia,  343,  9 

of  joints,  490 

of  stumps,  1007 

secondary,  343 

symptomatic,  343 

see  also  special  regions 

trifacial,  350 
Neuralgic  dysmenorrhea,  955 

ulcers,  990,  116 
Neurasthenia,  traumatic,  547 


Neurectasy,  342 
Neurectomy,  342 
Neurenteric  canal,  821,  553 
Neuritis,  342 

peripheral,  999 
Neurofibromatosis,  344 

varieties,  344 
Neurolysis,  345 
Neuroma,  343,  227 

false,  343 

true,  343 
Neuromimesis,  490 
Neuropathic  arthritis,  489 
Neuroplasty,  348 
Neurorrhaphy,  347 
Neurotomy,  342 
Nevolipoma,  222 
Nevus  flammeus,  226 

lymphatic,  227,  335 

pigmentosus,  249 

prominens,  226 

simple,  226 

venous,  226 
Nichol's   operation  for  resection  of  bone, 

437 
Night  cries,  481,  484 

pains,  197 

sweats,  113 
Nipple,  affections  of,  620 
Nitrous  oxid  gas,  29,  30,  22,  21 
Nocturnal  pollutions,  900 
Nodes,  gouty,  487 

Heberden's,  488 

Parrot's,  440 

syphilitic,  208,  502 
Nodules,  in  tumor  diagnosis,  243 
Noeggerath's  treatment  of  inversion   of 

uterus,  946 
Noguchi  serum  reaction  for  syphilis,  see 

Wassermann  reaction 
Noma,  136,  137,  2 

pudendi,  136 
Non-infectious  leukocytosis,  1 2 
Non-pathogenic  organisms,  43 
Non-pulsating  tumors  of  scalp,  502 
Non-union  of  fractures,  378,  385,  399 
Normal  salt  solution,  62 
Nose,  absence  of,  588 

adenoids,  595 

chronic  atrophic  rhinitis,  595 

clefts,  586 

crooked,  592 

deformities,  586 

epithelioma  of,  215 

fibromata  of,  594 


INDEX 


1061 


Nose,  foreign  bodies  in,  594 

frog,  586 

hammer,  586 

lupus  of,  250,  588 

ozena  of,  594 

plastic  operation  on,  586 

pol\-pi  of,  594 

saddle,  586 

sterilization  of,  67 

surgery  of,  586 

synechia  of,  594 

syphilis  of,  250,  586 

tuberculosis  of,  250,  594 

tuberous,  586 
Nourse,     operation     for    anteflexion     of 

uterus,  939 
Novocain,  38 

in  anesthesia,  31 

Objective  sj'raptoms,  in  diagnosis,  2 
Oblique  bandage,  77,  79 
facial  cleft,  636 

fractures,  374 

inguinal  hernia,  802      . 
Obliterating  appendicitis,  767 

cholecystitis,  780 
Obliteration  of  arteries,  303 
Obstructed  hernia,  820 
Obstruction,  intestinal,  741,  823 

of  bile  ducts,  787 

venous,  6,  7,  see  thrombosis 
Obstructive  dysmenorrhea,  956 
Obturating  thrombus,  266 
Obturator  dislocation  of  hip,  466 

hernia,  813,  817 

nerves,  affections  of,  359 
Occipital  artery,  compression  of,  312 

frontal  bandage,  80,  81 

ligation  of,  324 
Occluding  thrombus,  266 
Occupation,  in  diagnosis,  3 
Ochsner's  operation  for  esophageal  stric- 
ture, 662 

treatment  of  peritonitis,  680,  769 
Oculomotor  nerve,  affections,  24S 
Odontomata,  227 

cementoma,  228 

composite,  228 

compound  follicular,  228 

epithelial,  227 

fibrous,  228 

follicular,  228 

radicular,  228 
O'Dwyer's  intubation  tubes,  608 
Oidium  albicans,  51,  647 


Oil  of  cade,  6 
Oiled  silk,  60 
Ointments,  in  burns,  157 
Olecranon  bursa,  373 
fracture  of,  404 
Olfactory  nerve,  affections  of,  349 
Oligocythemia,  12 
Oilier,  bone  transplantation,  450 
Omental  hernia,  see  epiplocele 
Omentum,  affections  of,  686 
cysts  of,  687 
tears  of,  672 
tumors  of,  686 
volvulus  of,  686 
Omphalomesenteric  duct,  733,  677 
Onset,  in  diagnosis  of  tumors,  235 
Onychauxis,  255 
Onychia,  254,  198 
maligna,  255 
Onychocryptosis,  255 
Onychogryposis,  255 
Oophorectomy,  959 

for  cancer  of  breast,  220 
for  fibroids  of  uterus,  949 
for  osteomalacia,  443 
see  also  ovary 
Oophoron,  cysts  of,  966 
Open  fractures,  374 
Operating  room,  essentials  of,  68 

technic,  68,  69 
Operation,  after-treatment,  71 
in  private  house,  73 
plastic,  256 
preparation  of,  65 
assistants,  68 
nurses,  68 

patient,  69,  70,  ;i,  72 
surgeon,  68 
Operative  treatment  of  fractures,  381 
Opisthotonos,  179,  8 
Opium,  170 

poisoning,  514 
Opsonic  index,  50 
Opsonins,  48 
Optic  atrophy,  349 

nerve,  affections  of,  349 
neuritis,  349,  535 
Orbital  cellulitis,  597 
Orbitonasal  cleft,  634 
Orchitis,  acute,  904 
chronic,  905 

complicating  parotitis,  640 
syphilitic,  906,  198 
tuberculous,  905 
Organic  stricture  of  urethra,  890 


io62 


INDEX 


Organization  of  blood  clot,  102 

of  thrombus,  266 
Oriental  boil,  247 
Origin  of  tumors,  214 
Orthopnea,  8 
Orthotonos,  179 
Os  calcis,  fracture  of,  430 

see    talipes    for    osteotomy    of, 
policeman's   heel,    ostitis   of,   in 
flat-foot,  etc. 
magnum,    dislocation   of,    see   tarsal 
bones 
Osmic  acid,  injection  for  neuralgia,  349 
Ossicles  of  ear,  necrosis  of,  567 
Ossification  of  muscle,  364,  225 
Osteoarthritis,  488,  7 
Osteoarthropathy,      hypertrophic,      pul- 
monary, 431 
Osteoblasts,  379 
Osteochondritis,  syphilitic,  440 
Osteoclasis,  991 
Osteoclasts,  438 
Osteocopic  pains,  198,  438 
Osteodystrophia    juvenalis    of    Mikulicz, 

448 
Osteogenesis  imperfecta,  442 
Osteoma,  225,  see  also  special  regions 
durum,  225 
eburnated,  225 
spongiosum,  225 
Osteomalacia,  443,  375,  2,  3,  447 
Osteomyelitis,  4,  432 

acute  infectious,  432,  2 
chronic,  434 
diagnosis,  433 
gummatous,  439 
multiple,  433 
prognosis,  433 
recidiva,  433 
septic,  432 
syphilitic,  439 
treatment,  432 
tuberculous,  439 
typhoidal,  432,  434 
Osteoperiostitis,  431 
Osteophytes,  488,  431,  489 
Osteoplastic    amputations.     Bier's,    1019 
Gritti's,  102 1 
Moschcowitz,  1018 
Sabanejeff's,  1022 
resection  of  nose,  594 
skull,  508 
spine,  556 
Osteoporosis,  437,  431 
Osteopsathyrosis,  442 


Osteosarcoma,  229,  446 
Osteosclerosis,  434,  431 
Osteoscopic  pains,  198 
Osteotomy,  Adam's,  493 
cuneiform,  991 
for,  bow-legs,  991 
Colles  fracture,  408 
flat-foot,  996 
hallux  valgus,  998 
knock-knee,  989 
talipes,  991 
Macewen's,  990 
subtrochanteric,  493 
Ostitis,  chronic,  434 

condensing,  434,  431 
deformans,  445 

see  osteoarthritis 
fibrosa,  445,  438 
rarefying,  437,  43 1 
tuberculous,  480,  437 
typhoid,  434 
Othematoma,  566 
Otitis,  complications  of,  567 
cranial,  567 

carious  or  necrotic  ossicles,  567 
facial  paralysis,  567 
granulations  and  polypi,  567 
hemorrhages,  567 
mastoiditis,  568 
extracranial,  567 
intracranial,  570 
Otoplasty,  566 

Otorrhea,  intracranial  complications,  570 
Outward  dislocation  of  hip,  467 
Oval  method  of  amputation,  1004 
Ovarian  cysts,  966,  964 

complications  of,  967 
diagnosis  of,  969 
symptoms  of,  967 
treatment  of,  970 
dermoids,  969,  967,  233 
dysmenorrhea,  956 
hydrocele,  967 
pregnancy,  961 
Ovaries,  963 

apoplexy  of,  965 
atrophy  of,  965 
cirrhosis  of,  964 
congenital  malformation,  964 
cysts  of,  964,  233 
hematoma  of,  965 
hemorrhage  from,  965 
inflammation  of,  964 
prolapse  of,  963 
removal  of,  965,  440 


INDEX 


1063 


Ovaries,  tuberculosis  of,  965 

tumors  of,  965 
Ovariotomy,  970 
Ovaritis,  964 
Ovules  of  Xaboth,  933 
Ox>  butyric  acid,  129 

Oxygen  combined  with  ether  or  chloro- 
form, 29 
Ozena.  595 

Pachydermatocele,  221,  344 
Pachymeningitis,  529,  563 

external,  529 

internal,  529 
Pagenstecher's  thread,  62 
Paget's  disease,  444,  445 

disease  of  nipple,  620,  252 
bone,  see  ostitis  deformans 
Pain  in  diagnosis,  8 

character,  8 

in  inflammation,  93 

osteocopic,  198 

significance  of,  in  diagnosis  of  tumors. 
238 

also  see  special  regions 
Painful  feet,  998 

heel.  99S 

scars,  105 

stump,  1007 

subcutaneous  tubercle,  343 
Palate,  cleft,  652 

perforation  of,  654 
Palmar  abscess,  985 

cellulitis,  986 

fascia,  contraction  of,  980 

foreign  bodies,  980 

ganglion,  compound,  366 

sac,  366 

synovitis,  985 
Palpation  in  diagnosis,  9,  7 
Panaritium,  see  paronychia 
Panarthritis,  478 
Pancreas,  affections  of,  793 

calculi  of,  796 

cysts  of,  796 

inflammation  of,  793,  673 

rupture  of,  673 

tumors  of,  796 
Pancreatic  point  of  Desjardin,  795 
Pancreatitis,  793,  790 

acute,  794,  790 

chronic,  795 

gangrenous,  795 

interacinar,  795 

interlobular,  795 


Pancreatitis,  subacute,  795 

suppurative,  795 
Panhysterectomy,  951 
Panostitis,  acute,  432 
Papillitis,  349 
Papillomata,  215 

malignant,  215 
Papillomatous  cholecystitis,  780 
Papules,  197 

Papulo-squamous  syphilides.  197 
Paquelin  cautery,  100,  loi 
Paracentesis  abdominis,  684 

auriculi,  272 

pericardii,  276 

thoracis,  614 

ventriculi,  527 

vesicae,  871 
Paracolpitis,  929 
Paradoxical  embolism,  267 
Paraflin,  use  of,  for  cure  of  deformed  nose, 
586 
prolapse  of  rectum,  837 
Paraldehyd,  28 
Paralysis,  agitans,  545 

after  injur>^  to  brain,  512,  et.  seq. 
spinal  disease,  559,  563 
injuries.  546 

brachial  birth,  356 

following  injury  to  nerves,  345 

infantile,  564,  484,  2 

intestinal,  752 

post-anesthetic,  34,  356 
Paralytic  torticollis,  440 
Parametritis,  972 
Paraphimosis,  898 
Parasites,  43 
Parasitic  cysts,  233 

organisms,  43 
Parasyphilis,  200 
Parathyroid  glands,  576 

tetany,  576 
Parchment  crepitus,  8 
Parenchymatous  glossitis,  643 

goiter,  578 

hemorrhage,  307 

inflammation,  93 
Paresis,  342 

Parietal  mural  thrombus,  265 
Parietooccipital  fissure,  50^ 
Park  and  Nicoll's  treatment  of  tetanus, 

181 
Paronychia,  254,  198 
Paroophoron  cysts,  967 
Parotid  gland,  excision  of,  641 

IjTnph  gland,  affections  of,  641 


1064 


INDEX 


Parotid  tumors,  641 
Parotitis,  640 

suppurative,  640 
Parovarian  cysts,  965,  967 
Parrot's  nodes,  440 
Partial  gastrectomy,  725,  695 

hysterectomy,  950 

nephrectomy,  864 
Passage  of  urethral  bougies,  892 
Passive  incontinence  of  urine,  869 
Pasteur's     treatment     of     hydrophobia, 

184 
Patella,  dislocation  of,  470 

fractures  of,  421 
Pathetic  nerve,  affections  of,  ,350 
Pathogenic  organisms,  45 
Pathological  dislocations,  455 

fracture,  374 

treatment,  417 
nonoperative,  422 
operative,  423 
prognosis,  424 
Patten,  485 

Payr's  treatment  of  inoperable  angioma, 
227 

of  hydrocephalous,  529 
Pearls,  217 

Pedunculated  flaps,  257 
Pels-Leusden    treatment,    spina   ventosa, 

439 
Pelvic  cellulitis,  972 

hematocele,  972 

hematoma,  973 

neoplasms  of  connective  tissue,  974 

peritonitis,  971 
Pelvirectal  abscess,  830,  831 
Pelvis,  dislocation  of,  465 

fracture  of,  410 
of  false,  410 
of  true,  410 
Penis,  affections  of,  882 

amputation  of,  899 

balanitis  of,  898 

chancre  of,  193 

chancroid  of,  896 

congenital  malformation,  882 

epithelioma  of,  898 

extirpation  of,  899 

fracture  of,  896 

herpes  of,  195 

injuries  of,  896 

paraphimosis  of,  898 

phimosis  of,  897 

warts  of,  897 
Peptic  ulcers,  689 


Peptic  ulcers  of  jejunum  following  gastro- 
enterostomy, 723 
Percussion  in  diagnosis,  9 
Perforating  ulcer  of  duodenum,  732,  156 
of  foot,  999,  117 
of  stomach,  603 

typhoid  ulcer,  737 
Perforative  appendicitis,  767 

peritonitis,  678,  5 
Periadenitis,  337 
Periarteritis,  290 
Pericardial  effusions,  275 
Pericarditis,  275 
Pericardium,  275 
Pericardotomy,  276 
Pericholecystitis,  780 
Pericolitis,  734 
Pericystitis,  873 
Perigastric  adhesions,  695 

inflammation,  695 
Perihepatitis,  778 
Perineal  cystotomy,  880 

fistula,  891 

hernia,  817 

lithotomy,  880 

prostatectomy,  918 

relaxation,  924 

section,  880 
Perineorrhaphy,  924 
Perinephritic  abscess,  853 
Perinephritis,  853 
Perineum,  laceration  of,  923 
Periosteal  nodes,  440 

sarcoma,  446 
Periostitis,  431 

acute,  431 

albuminosa,  431 

chronic,  431 

ossifying,  431 

osteoplastic,  431 

purulent,  431 

serosa,  431 

simple,  431 
Peripheral  neuritis,  999 
Periphlebitis,  277 
Periproctitis,  830 
Perirectal  suppuration,  829 
Perirenal  hematoma,  853 
Perithelioma,  231 
Peritoneal  bands,  744 
Peritoneum,  malignant  disease  of,  684 
Peritonitis,  678 

acute  diffuse,  679 
localized,  678 

chronic  simple,  682 


INDEX 


1065 


Peritonitis,  pelvic,  971 

perforative,  679,  5 

tuberculous,  682 
Periurethral  abscess,  889 
Permanent  torticollis,  573 
Permanganate  of  potash,  54 
Pernicious  anemia,  306,  798 
Pernio,  160 

Peroneal  artery,  ligation  of,  334 
Peronei  tendons,  tenotomy  of,  366 
Perthes'   operation   on    biliary    passages, 

788 
Pertussis,  600 
Pes  cavus,  996 

planus,  994 
Pesquin's  operation  for  aneurysm,  303 
Pessaries,  941 
Petechiae,  138,  6,  168 
Petit  de  la  Villeon's  method  removing 
foreign  bodies  from  lungs,  611 
Petit's  tourniquet,  312 
Petrissage,  98 
Petrosal  sinus,  hemorrhage  from,  567 

thrombosis  of,  532 
Pfannenstiel  incision,  942 
Phagedena,  120,  897 
Phagocytosis,  48 
Phalanges,  amputation  of,  1009,  1015 

dislocation  of,  465 

fracture  of,  430,  410 
Phantom  tumor  of  abdomen,  677 
Pharyngocele,  657 
Pharyngotomy,  subhyoid,  605 

transhyoid,  605 
Pharynx,  burns  of,  159 

epithelioma  of,  217 
Phelps'  operation  for  talipes,  993 

for  varicose  veins,  283 
Phenol,  s^ 
Phenolsulphonephthalein    test    of  kidney 

function,  845 
Phimosis,  2,  897,  538 
Phlebectasia,  279 
Phlebitis,  277 

acute,  277 

chronic,  279 

exudative,  277 

pathology  of,  277 

post-operative,  277 

prophylaxis  of,  278 

suppurative,  277 
Phleboliths,  266 
Phleborrhaphy,  316 
Phlebosclerosis,  279 
Phlebotomy,  284 


Phlegmasia  alba  dolens,  278 
Phlegmone  ligneuse  du  cou,  575 
Phlegmonous  erysipelas,  175 

inflammation,  93 
Phloridzin   test  of   kidney   function,   845 
Phosphorous  burns,  159 

poisoning,  306,  3 
Phosphorus  necrosis  of  jaw,  435,  648,  650 
Photophobia,  534 
Phrenic  nerve,  injury  of,  354 
Physical  examination,  in  diagnosis,  i 
Physiologic  salt  solution,  63 
Physometra,  931 

Picric  acid  in  treatment  of  burns,  157 
Piles,  834 

Pirogoff's  amputation,  1017 
Pituitary  body,  tumors  of,  537 
Placenta,  retained,  167 
Plague,  49 

Plantar  fascia,  tenotomy  of,  367 
Plantaris  muscle,  rupture  of,  991 
Plasmodium  malariae,  51 
Plaster-of-Paris  dressing,  89 

splints,  89,  76 
Plastic,  arteritis,  290 

inflammation,  93 

linitis,  706 

splints,  381 

surgery,  255 
Pleiad  of  Ricord,  193 
Pleural  cavity,  affections  of,  611 
aspiration  of,  614 
effusion  into,  613 
tapping  of,  614 
Pleurectomy,  617 
Pleurisy,  613,  6 
Pleuropneumonia,  269 
Pleurosthotonos,  179,  11 
Plexiform  angioma,  226,  294 

neuroma,  344 

sarcoma,  231 
Pneumatocele,  525 
Pneumectomy,  618 
Pneumocele,  611 
Pneumococcal  arthritis,  479 

empyema,  614. 
Pneumococcus,  107,  432,  613 
Pneumogastric  nerve,  affections  of,  354, 

580 
Pneumohemothorax,  273,  610 
Pneumolysis,  618 

Pneumonia,    14,   35,    170,    173,    273,   611 
Pneumothorax,  611,  818 
Pneumotomy,  617 
Point  of  Desjardin,  795 


io66 


INDEX 


Points  douloureux,  343,  350 
Poisoned  wounds,  152 
Poisoning,  alcohol,  514,  342 

arsenic,  342 

bichlorid  of  mercury,  52,  53 

blood,  166 

carbolic  acid,  53 

chloroform,  34,  172 

cocain  hydrochlorid,  37 

ergot,  130,  6 

iodm,  54 

iodoform,  55 

lead,  535 

opium,  514 

phosphorous,  306,  3 

snake,  154,  6 

strychnia,  180 
Policeman's  heel,  998 
Poliomyelitis,  acute  anterior,  564 
Pollutions,  diurnal,  900 

nocturnal,  900 
Polonium,  20 

Polya's  method  in  pylorectomy,  72S 
Polycystic  disease  of  liver,  775 
Pohxythemia,  156,  11 
Polydactjdism,  978 
Polymastia,  620 

Polymorphonuclear  leukocytes,  12,  13 
Polymyositis,  364 
Polyneuritis,  342 
Polynuclear  count,  13 
Polyorchism,  902 
Polypi,  220 

see  special  regions 
Polyserositis,  778 
Polythelia,  620 
Pond-shaped  fracture,  51& 
Poole's  operation,  thyroid  gland,  576 
Popliteal  arter}',  compression  of,  313 
ligature  of,  332 

bursae,  373 

nerve,  injury  of,  see  internal  and  ex- 
ternal 
Portal  cirrhosis  of  the  liver,  777 
Post-anal  dimple,  see  spina  bifida  occulta 

gut,  554 
Post-anesthetic  paralysis,  36,  356 
Post-calcaneal  bursitis,  998 
Posterior  colporrhaphy,  924 

gastroenterostomy,  713 

thoracic  nerve,  injury  of,  357 

tibial  artery,  compression  of,  313 
ligature  of,  ^3^ 
Post-febrile  gangrene,  129 
Posthitis,  898 


Post-incisional  hernia,  816 
Post-mortem  wounds,  152 
Post-nasal  adenoids,  595 
Post-operative  backache,  72 

constipation,  72 

dressings,  73 

feeding,  73 

fever,  72 

hemorrhage,  72 

hernia,  816 

insomnia,  72 

nervousness,  72 

pain,  72 

phlebitis,  278 

pulse,  72 

retention  of  urine,  71 

shock,  71 

thirst,  72 

treatment,  71 

vomiting,  72 
Post-pharyngeal  abscess,  559,  655 
Posture  in  diagnosis,  11 
Potassium  permanganate,  54 
Pott's  disease,    557,   see   spine   tubercu- 
losis 

fracture,  426,  471 
symptoms,  428 
treatment,  428 

puffy  tumor,  532 
Poultice,  99 

Powders,  in  aseptic  wounds,  55 
Precancerous  dermatoses,  252,  242 
Precentral  sulcus,  503 
Precipitins,  48 
Pregnancy,  970,  279 

abdominal,  961 

ectopic,  961 
Preliminary  colostomy,  841 

tracheotomy,  606 
Preparation  of  instruments,  59 

patients  for  operation,  65 
Prepatellar  bursa,  373 
Prepuce,  incision  of,  898 
Presenile  gangrene,  128 
Pressure,   gangrene   following,    132,    127, 
378,  312,  98,  76 

symptoms,  in  tumor  diagnosis,  238 

treatment  for  aneurysm,  301 

ulcers,  117 
Preternatural  mobility  in  fracture,  377 
Priapism,  899 
Primary  anesthesia,  25 

hemorrhage,  307 

syphilis,  191 

thrombus,  265 


INDEX 


1067 


Primary  union  of  wounds,  102 
Primitive  aneurysm,  296 
Private  house,  operation  in,  73 
Procain,  38 
Procidentia,  943 
Proctectomy,  841 
Proctitis,  829,  9 

gonorrheal,  886 
Proctodeum,  826 
Proctolysis,  682 
Proctopexy,  838 
Productive  arteritis,  290 
Profeta's  law,  192 
Proflavine,  55 
Prognathism,  444 

Progress  of  tumors  in  diagnosis,  236 
Progressive  muscular  atrophy,  557 

pernicious  anemia,  306 
Prolapse,  see  special  organs 
Proliferous  mammary  cyst,  625 
Prominent  ears,  566 
Propagating  thrombus,  266 
Preperitoneal  hernia,  804 
Proptosis,  see  exophthalmos 
Prostate,  affections  of,  914 

abscess,  914 

calculi,  915 

carcinoma  of,  915,  918 

hemorrhage  from,  847 

hyTsertroph}^  of,  915 

tuberculosis,  914 
Prostatectomy,  917 
Prostatitis,  914 
Prostatorrhea,  914 
Prostatotomy,  917 
Protopathic  nerve-fibers,  346 
Protozoa,  51 
Proud  flesh,  103 
Pruritus  ani,  829 

vulvae,  922 
Psammoma,  230 
Pseudoarthrosis,  456,  385 
Pseudodiverticula,  esophageal,  657 
Pseudoelephantiasis,  336 
Pseudohermaphrodism,  921 
Pseudohydrophobia,  185 
Pseudohypertrophic  paralysis,  557 
Pseudoleukemia,  339,  796 
Pseudomembranous  cholecystitis,  780 

inflammation,  93 
Pseudoobstruction,  intestinal,  752 
Pseudopodium,  92 
Pseudoprolapse  of  uterus,  944 
Pseudotrichinosis,  364 
Psoas  abscess,  559,  806 


Psoriasis  linguae,  643 

palmar,  197 

plantar,  197 

syphilitic,  197 
Ptomains,  45 
Ptosis,  349,  533 
Ptyalism,  202 

Pubic  dislocation  of  hip,  466 
Pudendal  hernia,  817 
Puerperal  peritonitis,  see  peritonitis 
Pulmonary  affections  in  anesthesia,  35 

alveolar  emphysema,  619 

decortication,  617 

embolism,  269 

gymnastics,  617 

hemorrhage,  610 

hypertrophic  osteoarthropathy,  431 

tuberculosis,  operation  for,  618 
Pulpy    degeneration    of    synovial    mem- 
brane, 480 
Pulsating  empyema,  613 

exophthalmos,  521 

tumors  of  bone,  446,  447 
of  scalp,  501 
Psulsation,  in  diagnosis,  6 
Pulse,  character  of,  after  operation,  72 

in  diagnosis,  10 

in  septicemia,  168 
Pulsus  paradoxus,  275 
Punctured  fracture,  375,  516 

wounds,  144 
Purgation,  in  sepsis,  172 
Purpura,  245 

hemorrhagica,  306,  592 
Purulent  effusion  of  pericardium,  275 

infiltration,  177 

inflammation,  93 
Pus,  108 

varieties  of,  108 
Pusey's  method  for  inoperable  angiomata, 
227 

treatment  for  nevi,  227 
Pustule,  197 
Pyelitis,  851 

modes  of  infection  in,  851 
Pyelography,  843 
Pyelolithotomy,  864 
Pyelonephritis,  852 
Pyelostomj',  864 
Pyelotomy,  864 
Pyemia,  6,  275,  289,  567,  169,  171 

actinomycotic,  189 

acute,  169 

chronic,  169 

in  diseases  of  bones,  433 


io68 


INDEX 


Pyemia  in  diseases  of  the  ear,  567 

in  joint' diseases,  477,  479 

lateral  sinus,  531,  279 

symptoms,  169 
Pyemic  abscess,  109 

synovitis,  477 
Pylephlebitis,  169 
Pylorectomy,  726,  695,  697 
Pylorodiosis,  728 
Pyloroplasty,  725 
Pylorus,  stenosis  of,  699 

exclusion,  723 

occlusion,  723 
congenital,  688 

tumors  of,  723 
Pyogenic  bacteremia,  168 

bacteria,  106 

infections,  167 

toxemia,  167 
ulcer,  116 
Pyometra,  931 
Pyonephrosis,  852 
Pyopericarditis,  275 
Pyorrhea  alveolaris,  648 
Pyosalpinx,  958 
Pyothorax,  613 
Pyrexia,  1&7 
Pyuria,  847 

Qualitative  food  dyspepsia,  785 

Quenu's    operation    for    excision    of    the 

rectum,  842 
Quiet  necrosis,  435 
Quilled  suture,  141 
Quinine-urea  hydrochloride,  38 
Quinsy,  654 

Rabic  tubercles  of  Babes,  183 
Rabies,  183,  182 
Racemose  adenoma,  216 

aneurysm,  226,  294 
Rachischisis,  551 
Rachitic  rosary,  441 
Rachitis,  440 

Racquet  method  of  amputation,  1005 
Radial  artery,  compression  of,  313 

ligation  of,  328 
Radical  resection  of  joints,  495 
Radicular  odontoma,  228 
Radiograph,  15,  16 

interpretation  of,  15 
Radiography,  15 
Radiotherapy,  19 
Radium,  20 

bromid,  20 


Radium,  in  diagnosis,  20 
rays,  20 
therapy,  20 
Radius,  congenital  absence  of,  978 
dislocation  of,  463 
fractures  of,  405 
head,  405 

lower  end  (Colics'),  406 
neck,  405 
shaft,  406 
separation  of  lower  epiphysis,  408 
subluxation  of  head  of,  463 
Radius  and  ulna,  dislocations  of,  463 

fractures  of,  408 
Railway  brain,  546 

spine,  546 
Rammstedt     operation     for     congenital 

stenosis  of  pylorus,  689 
Randolph  bandage,  122 
Ransohoff's  arterial  anesthesia,  39,  40 
discission  of  the  lungs,  617 
skeletal  calipers,  419 
Ranula,  641,  232 
Rapid  spiral  bandage,  77 
Rarefaction  of  bone,  437,  431 
Rashes  of  bichlorid  of  mercury,  170 
carbolic  acid,  170 
ether,  170 
iodoform,  170 
septic,  170 
syphilis,  197 
Ray  fungus,  188 
Raynaud's  disease,  127,  129,  3,  6 

gangrene,  129 
Reactionary  fever,  166 

hemorrhage,  307 
Reactions  of  degeneration,  346 
Reason,  center  of,  506 
Receptors,  48 

Recklinghausen's  disease,  344 
Rectal  anesthesia,  28 

hernia,  817 
Rectocele,  924 
Rectovaginal  septum,  laceration  of,  923 

fistula,  928 
Rectovesical  fistula,  928 
Rectum,  abscess,  830 
absence  of,  827 
afi'ections  of,  825 
atresia  of,  827 
carcinoma  of,  839 
cellulitis  about,  830 
colostomy  in  carcinoma  of,  840 
congenital  malformation  of,  826 
control  of  hemorrhage  from,  311 


INDEX 


1069 


Rectum,  excision  of,  840 

abdomino-pcrincal  route,  842 
anal  route,  841 
perineal,  841 
sacral.  841 
vaginal  route,  841 
foreign  bodies  in,  828 
imperforate,  827 
inflammation  of,  829 
injuries  of,  828 
papilloma,  839 
polypi,  839 
prolapse,  837 
sarcoma,  839 
sterilization  of,  67 
stricture  of,  838 
syphilis  of,  838 
tuberculous  disease  of,  838 
tumors  of,  839 
ulcers  of,  838 
Rectus   abdominis    muscle,    diastasis    of, 

816 
Recurrent  appendicitis,  769 
hemorrhage,  307 
laryngeal  nerve,  pressure  upon,  580, 

297 
shoulder  dislocation,  461 
bandage,  77,  79 
Red  blood  corpuscles,  1 1 

basophilic  granulations  in,  14 
in  inflammation,  91 
infarct,  268 
thrombus,  265 
death,  135 
Redness  in  inflammation,  94 

in  diagnosis,  6 
Reducible  hydrocele,  911 
swellings,  805 
in  diagnosis,  241 
Reduction  en  bloc  of  a  hernia,  805,  742 
en  masse  of  a  hernia,  805 
of  dislocations,  457,  461,  468 
of  fracture,  380 
Reef  knot,  142,  320 
Reel  feet,  992 
Referred  pain,  8 

in  hip  disease,  483 
renal  disease,  856 
spinal  caries,  561 
vesical  calculus,  876,  877 
Reflex  anuria,  848,  857 

inflammation,  93 
Regeneration,  103 

of  brain,  523,  103 
glandular  organs,  103 


Regeneration  of  lymphatic  tissue,  103 
nerves,  347,  104 
spinal  cord,  551,  103 
Rehn's  method  of  controlling  hemorrhage 

while  suturing  the  heart,  274 
Reid's  method  of  compressing  aneurysms, 

300 
Relapsing  appendicitis,  769 
Relaxation  incisions,  256 
Renal  calculus,  855 

appearance,  856 
causes,  855 
symptoms,  856 
treatment,  860 
colic,  668,  857 

complications  in  anesthesia,  36 
function,  estimation  of,  846 
hematuria,  847 
hemophilia,  850 
Repair,  102 

granulation,  102 
healing  by  first  intention,  102 
non-vascular  tissue,  103 
second  intention,  102 
third  intention,  103 
of  bone,  103  (also  Chapter  XIX) 
blood  vessels,  103 
cartilage,  103 
fractures,  378 
muscles,  103 
skin,  103 
tendons,  103 
of  tissue,  loi 
phenomena  of,  102 
primary  union,  102 
Reposition  of  a  retroverted  uterus,  940 
Resection,  see  special  regions 
Residual  abscess,  109 

urine,  916,  871 
Resolution  in  inflammation,  93 
Resorption  fever,  166 
Respiration,  artificial,  33 

Cheyne-Stokes,  512,  533,  535 
Respiratory  system,  surgery  of,  586 

difiiculties  during  anesthesia,  28 
Rest,  in  inflammation,  95 
Restlessness,  significance  in  diagnosis,  11 
Restoration  of  function  in  treatment  of 

fractures,  381 
Retained  placenta,  167 

testis,  903 
Retention  cysts,  232 
of  fractures,  380 
of  urine,  71,  870 
suture,  141 


1070 


INDEX 


Retiform  l\-mphangitis,  337 
Retinal  hemorrhage,  520 
Retinochoroiditis,  199 
Retractors,  1002 
Retrocalcaneal  bursa,  998,  573 
Retrocollis,  572 

Retroflexion  of  uterus,  938,  939 
Retrograde  embolism,  267 

esophageal  dilatation,  662 

strangulated  hernia,  823 
Retroperitoneal  abscess,  687 

hernia,  819 

locations  of,  819 

tumors,  687 
Retrophar\-ngeal  abscess,  559,^655 
Retroversion  of  uterus,  938,  939,  942 
Reverdin's  method  of  skin  grafting,  262 
Rhabdomyoma,  225 
Rhagades,  207 
Rheumatic  arthritis,  487 

gout,  488 

myositis,  364 

synovitis,  475 

torticollis,  572 
Rheumatism,  gonorrheal,  479,  433 
Rheumatoid  arthritis,  see  osteoarthritis 
Rhinitis,  596 

gonorrheal,  886 
Rhinolith,  594 
Rhinophyma,  586 
Rhinoplasty,  586 
Rhinoscleroma,  586 
Rhinoscopy,  594 
Ribs,  cervical,  574 

dislocation  of,  465 

fracture  of,  391 

resection  of,  616 
Rice  bodies,  490,  365,  372,  481,  see  also 

melon-seed  bodies 
Richter's  hernia,  801 
Rickets,  2,  377,  440 
Rider's  bone,  364 

leg,  362 
Riedel's  lobe  of  liver,  776,  786 
Rigg's  disease,  648 
Risus  sardonicus,  179,  11 
Riziform  bodies,  see  rice  bodies 
Roberts'  operation  for  fracture  of  patella, 

423 
pericardotomy,  276 
pins,  592,  387 
splint,  407 
Robson's  operation   on   biliary   passages, 

788 
point,  784 


Rodent  ulcer,  251,  19 
Rogers'  treatment  of  tetanus,  181 
Rogers   &   Torreys   treatment  of  gonor- 
rheal arthritis,  480 
Roidium  albicans,  51 
Rolando,  fissure  of,  503 
Roller  bandage,  76 
Rollier's  sun  bath,  212 
Roman  nose,  586 
Rongeur  forceps,  508 
Rontgen  rays,  14 

burns,  acute,  19 
chronic,  252,  19 

danger  from,  19 

detection  of  foreign  bodies,  17,  144, 

523 
renal  calculus,  857,  858 
ureteral  calculus,  857,  858,  17 
vesical  calculus,  17 
diagnosis,  17 
aneurj-sm,  298 
fractures,  17,  378 
of  diseases  of  bone,  447 
pericardial  effusions,  275 
stomach,  size,  shape,  position,  and 
activitN'  of,  702 
gangrene  following,  19,  134 
interpretation  of  pictures,  15,  16 
stereoscopic  plates,  18,  19 
therapeutic  effects  of,  18 
treatment  of  acne,  18 
actinomycosis,  188 
blastomycosis,  18,  246 
carcinoma,  19,  250,  219 
comedo,  18 
favus,  18 

goiter,  18,  578,  579 
hemangioma,  220 
h\-pertrichosis,  18 
keloid,  249 

rodent  ulcer,  18,  220,  249 
sarcoma,  231,  19 
of  skin,  251 
tenia  barbae,  18 
tonsurans,  18 

treatment  of  lupus,  18,  248 
tuberculous  lesions,  212 
untoward  effects,  19 
Rosary,  rachitic,  440 
Rose  position,  635 

operation  for  the  removal  ofithe^Gas- 
serian  ganglion,  353 
Rotch's  sign,  275 
Round-celled  sarcoma,  229,  445 
Round  ligament,  hydrocele  of,  911 


INDEX 


IO71 


Round  ligament,  shortening  of,  943 
Roux's  gastroenterostomy,  722 
Rubber  bandage,  76 
Rubber  gloves,  64 

sterilization  of,  64 
Rubefacients,  100 
Run  around,  254 
Rupia,  197 
Rupture,  799 

of  organs  and   tissues,  see  special 
regions 
Rydygier's  method  of  splenopexy,  797 

Sabanejeff's  amputation  of  femur,  1022 
Sabre  blade  deformity,  991 
Sac  of  hernia,  800 
Saccharomycetes,  51 
Sacculated  aneurysm,  296 
Sacral  cysts,  553 

plexus,  injuries  to,  360 

tumors,  congenital,  553 
Sacrococcygeal  fistulae,  554 

tumors,  553 

varieties,  553 
Sacroiliac  joint,  tuberculosis  of,  482 
Sacro-pubic  bandage,  88 
Sacrum,  fractures  of,  411 

sarcoma  of,  553 
Saddle  nose,  586 
Sahli's  sign  of  pancreatitis,  795 
Saline  infusion,  287 
Salivary  calculus,  641 

cysts,  641 

fistula,  642 
*         glands,  affections  of,  640 
Salivation,  202 
Salpingitis,  957 

tuberculous,  965 
Salpingo-oophorectomy,  959 
Salpingostomy,  960 
Salt  solution,  normal,  38,  63 
Salvarsan,  203 
Sanitary  tube  in  treatment  of  gonorrhea, 

887 
Sapremia,  167 
Saprophytes,  43,  107 
Sarcinae,  42 

Sarcocele,  syphilitic,  906,  198 
Sarcoma,  228,  231 

alveolar,  229 

curative     action     of    erysipelas    on, 
231 

skin,  253 

see  mesoblastic  tumors 
see  also  special  regions 


Sarcomatosis,  229 

saucer  fracture,  516 
Satellite  bubo,  193 
Sauerbruch's  operating  cabinet,  612 
Sayre's  jury  mast,  562 
plaster  jacket,  561 
treatment    of    fracture    of    clavicle, 

392,  394 
tripod,  563 
Scalds,  155 

Scalp,  affections  of,  500 
abscess,  501 
contusions,  500 
hematoma,  500 
meningocele,  501 
spuris,  501 
traumatic,  501 
pachydermatocele,  502 
tumors,  501 
wounds,  501 
Scalpel,  methods  of  holding,  70 
Scaphoid  bone,  bipartite,  409 
excision  of,  409 
fracture  of,  409 
Scapula,  alatum,  975 

acromion  process,  395 
anatomical  neck,  394,  395 
body,  394 

coracoid  process,  395 
surgical  neck,  395 
congenital  elevation  of,  975 
dislocation  of,  975 
fracture  of,  395 
winged,  975 
Scarlatina,  surgical  169 
Scarlatinal  arthritis,  478 
Scarpa's    triangle,    ligation    of    femoral 

artery  in,  334 
Scars,  104,  105 

epithelioma  in,  104 
Schafer's  method  for  artificial  respiration, 

34 
Schede's    operation    for    varicose    veins, 

283 
of  thoracoplasty,  617 
Schizomycetes,  42 
Schleich  s  solution,  38 
Schnappende  Hiifte,  988 
Schreiber's    procedure    in    administering 

neoarsphenamin,  205 
Schultz's  treatment  of  ulcers,  123 
Schwartze's  operation  for  mastoid  disease, 

568 
Schwartze-Stacke  operation   for  mastoid 

disease,  569 


1072 


INDEX 


Sciatic  artery,  ligation  of,  330 
dislocation  of  hip,  466 
hernia,  817 

nerve,  operation  on,  360 
Sciatica,  360,  483 
Scirrhus,  carcinoma,  218 
of  breast,  626 
ulcer,  626 

see  special  regions 
Sclavo's  serum,  187 
Sclerosis  of  bone,  434 
diffuse,  199 
of  testicle,  198 
Sclerotitis,  gonorrheal,  887 
Scoliosis,  554,  4 

pathological  anatomy  of,  554 
symptoms,  554 
treatment,  556 
Scopolamin-morphin  anesthesia,  31 
Scorbutic  ulcers,  118 
Scotch  douche,  100 
Scrofula,  208 
Scrofuloderma,  250 

Scrotal  tumors,  general  diagnosis  of,  907 
bandage,  88 
hernia,  802,  806 
Scultetus'  bandage,  86 
Scurvy,  infantile,  433,  441 

rickets,  433,  441 
Sebaceous  cysts,  232,  254 

horn,  254 
Secondary  hemorrhage,  307 
infection,  45 
neuralgia,  34^ 
neurorrhaphy,  347 
perineorrhaphy^,  924 
sarcoma  of  bone,  445 
suture,  149 
syphilis,  171 
thrombus,  266 
union  of  wounds,  102 
Section  of  nerves,  345 

perineal,  880 
Sedillot's  excision  of  tongue,  647 
Segregation  of  the  intestine,  764 
Semilunar  cartilage,  displacement  of,  471 
Semimembranous   tendon,    tenotomy   of, 

367 
Seminal  vesicles,  affections  of,  913 
emissions,  involuntary,  900 
tuberculosis,  913 
Semitendinosus  tendon,  tenotomy  of,  367 
Senile  atrophy  of  bone,  442 

enlargement  of  prostate,  915 
gangrene,  127 


Senile  keratosis,  252 
tuberculosis,  209 
Senn's  decalcified  bone  chips,  436 

method  of  amputation  of  the  hip, 

1024 
operation    for   floating    kidney,    848 
Sensation  in  diagnosis,  8 

nerve  fibers  of  deep,  346 
Sensory  aphasia,  506 
Sentinel  pile,  829 
Separation  of  epiphyses,  375 
Sepsis,  166 

causative  lesion  of,  170 
diagnosis  of,  170 
forms  of,  170 
treatment  of,  171 
Septic  arthritis,  478 
emboli,  see  pyemia 
intoxication,  167,  171 

chronic,  167 
symptoms,  167 
Septicemia,  168 

cryptogenic,  168 
local  manifestations,  169 
primary,  168 
secondary,  168 
symptoms,  168 
Septum,  deviation  of,  592 
nasi,  fracture  of,  386 
Sequestration  dermoids,  233 
Sequestrotomy,  436 
Sequestrum,  434,  435,  126 
Serodiagnosis,  14 
Serotherapy,  49 
Serous  cysts,  232 

effusion,  in  pericardium,  275 

pleural,  613 
inflammation  93 
membranes,  inflammation  of,  8 
synovitis,  475 
Serum,  antidiphtheritic,  25,  loi 
antistreptococcic,  171 
disease,  49 
immunity,  49 
antitoxic,  49 
bactericidal,  49 
Seventh  nerve,  affections  of,  353 
Sex,  in  diagnosis,  3 
Shape  of  lesion  in  diagnosis,  5 
tumors,  in  diagnosis,  239 
Sheep  serum,  185 
Sherman  black  sheets,  69 
Shock,  163,  171 
causes,  163 
prophylaxis,  164 


INDEX 


1073 


Shock,  symptoms,  164 

treatment,  165,  13Q 
apathetic,  164 
dehiyed,  164 
eresthistic,  164 
secondary,  164 
torpid,  164 
Short-circuiting    operation    on    intestine, 

764 
Shoulder,  amputation  through,  1012 

ankylosis  of,  491 

congenital  elevation  of,  975 

dislocation  of,  459,  463 

effusion  into,  476 

excision  of,  496 

osteoarthritis  of,  489 

tuberculosis  of,  482 
Shroeder's  amputation  of  cervix,  933 
Side-chain  theory  of  Ehrlich,  48 
Sigmoid  flexure,  volvulus  of,  745 
Sigmoidoscope,  826 
Sigmoidostomy,  755 
Signs,  in  diagnosis,  7 
Silicate  of  soda  dressing,  90,  76 
Silk,  60 

Silkworm  gut,  60 
Silver  nitrate,  55 

salts  of,  55 

wire,  62 
Simple  carcinoma,  218 

of  breast,  626 

dislocation,  453 
Simple  fracture,  374 

goiter,  577 

inflammation,  91 

ulcer,  116,  119 
Sims'  position,  919 

for  peritonitis,  68 1 

sound,  921 

speculum,  919 

uterine  curette,  936 
Simulation  of  surgical  conditions,  14 
Sinus,  124 

affections  of,  596 

see  also  special  regions 

treatment,  124 
Situation  of  lesion,  in  diagnosis,  5 

of  tumors  in  diagnosis,  238 
Sitz  bath,  99 

Sixth  ner\-e,  injuries  of,  353 
Size  of  lesion,  in  diagnosis,  5,  538 

tumors,  in  diagnosis,  237,  239 
Skeletal  calipers,  419 
Skey's  method  of  amputating  foot,  1016 
Skiagraph,  15 
6S 


Skiagraph,  interpretation  of,  15 
Skiagraphy,  see  Rontgen  rays,  14 
Skin,  anesthesia  of,  following  section  of 
nerves,  345 

carcinoma,  252 
lenticular,  252 
treatment  of,  252 

color  of,  changes  in,  5 

disinfection,  54 

epithelioma  of,  251 
deep,  252 
nodular,  252 
superficial,  251 

grafting,  260 

hemorrhagic,  245 

idiopathic  multiple,  253 

in  relation  to  tumors,  243 

lesions  in  syphilis,  196 

leukemic  tumors,  253 

mycosis  fungoides,  253 

pedunculated  flaps,  257 

preparation  of,  for  operation,  66 

sarcoma,  253 

surgery  of,  245,  256 

tuberculosis  of,  249 

tumors  of,  242 

warts,  216 
Skinner's  inhaler,  28 

mask,  28 
Skull,  atrophy  of,  443 

fracture  of,  515,  516 
base,  517 
vault,  516 

gunshot  injuries  of,  516,  14S 

natiform,  207 

necrosis  of,  207 

syphilitic  necrosis,  440 

trephining  of,  507 

varieties,  515,  516 
Sleeping  sickness,  51 
Sliding  hernia,  799 
Slough,  126,  116 
Sloughing,  126 
Small-pox,  50 

Small  sciatic  ner\^e,  affections  of,  360 
Smell,  sense  of,  in  diagnosis,  10 
Smith's,  Xathan  R.,  splint,  418 

Stephen,  clamps  for  hemorrhoids,  836 
treatment  of  dislocation  of  shoul- 
der, 461 
Snake  bites,  154,  153 

poisoning,  154,  54,  53 
Snap-finger,  979 
Snapping  hip,  988 
Snare,  594 


I074 


INDEX 


Snuffles  in  syphilis,  206 

Social  condition,  in  diagnosis,  3 

Sodium  cacodylate  for  syphilis,  205 

citrate  method  blood  transfusion,  287 
Soft  carcinoma,  218 

chancre,  896 

corn,  248 

of  breast,  626 
Softening  in  tumors,  241 
Solar  plexus  blow,  611 
Sole,  perforating  ulcer  of,  999 
Solitary  kidney,  843 
Soot  warts,  252 
Sounding  the  urinary  bladder,  method  of, 

877 
Sounds,  see  special  regions 
Spasm  of  esophagus,  660 

intestine,  748 

of  pharyngeal  muscles,  179 

of  respiratory  muscles,  32 
Spasmodic  croup,  599 

stricture  of  urethra,  890 

stump,  1007 

torticollis,  572 
Spastic  ileus,  748 

paraplegia,  544 
Special  fractures,  386 
Specific  inflammation,  93 

ulcer,  116 
Spence's   amputation   at   shoulder   joint, 

1013 
Spermatic     cord,     hematocele     of,     912 
hj^drocele  of,  911 
torsion  of,  904 
Spermatocele,  911 
Spermatorrhea,  900 
Sphacelation,  126 
Sphacelus,  126 

Sphenoidal  sinuses,  diseases  of,  597 
Spica  bandage,  77 

descending,  83 

of  foot,  87 

of  groins,  87 

of  shoulder,  82 

of  thumb,  81 
Spiller-Frazier  operation  for  the  removal 
of  the   Gasserian   ganglion,   353 
Spina  bifida,  551 

anterior,  552 
occulta,  551 
ventosa,  438 
Spinal  accessory  nerve,  affections  of,  354 
stretching  of,  573 

anesthesia,  40 

caries,  558 


Spinal  cord,  compression  of,  547 

concussion  of,  546 

contusion  of,  546 

diseases  of,  11,  552 

edema  of,  547 

hemorrhage  into,  548,  549,  550 

injuries  of,  546 

pressure  on,  in  Pott's  disease,  562 

resection  of  posterior  roots  of,  544 

total  transverse  lesion  of,  541 

tumors  of,  564 

wounds  of,  551 
curvature,  554 
hemorrhage,  551,  546,  547 
localization,  539 
membranes,  tumors  of,  564 
meningitis,  563 
neurasthenia,  547 

puncture,  544,  see  lumbar  puncture 
rickets,  556,  551 
traumatic  neurosis,  546 
Spindle-celled  sarcoma,  230 
Spine,  abscess  from,  559,  562 
aneurN^smal  erosion  of,  556 
ankylosis  of,  489,  557 
caries  of,  558 
concussion  of,  535 
congenital  malformation  of,  553 
curvatures  of,  554 
deformities  of,  554,  3 
diseases  of,  551,  483 
dislocations  of,  549 

varieties,  549 
fracture  of,  547 
fracture-dislocation  of,  547 
injuries  of,  546 
osteoarthritis  of,  558 
osteomyelitis  of,  557 
sprains  of,  546 
surgery  of,  539 
tuberculosis  of,  557 

diagnosis,  560 

local  symptoms,  564 
abscess,  559,  563 
deformity,  562 
pain,  558 

paralysis,  560,  563 
rigidity,  558 

pathology,  558 

treatment,  560 
of  abscess,  563 
tumors  of,  553,  564 
Spiral  bandage,  77 

of  finger,  81 

of  chest,  84 


INDEX 


i075 


Spiral  biiiula^e,  reversed,  S2 

fracture,  374 

reversed  banduRC,  77 
of  lower  extremity,  87 
Spirilla,  42 

Spirochcta  pallida,  191,  43,  5r,  194 
Splanchnoptosis,  739 
Splay  foot,  994 
Spleen,  abscess,  797 

affections  of,  797 

rupture  of,  672,  797 
Splenectomy,  797 

blood  changes  after,  799 

contraindications,  798 
Splenic  anemia,  798 

fever,  185 
Splenomegaly,  797 
Splenopexy,  797 
Splenoptosis,  797 
Splint,  381,  396 

Agnew,  422,  396 

Band, 390 

Bond,  396,  407 

Dupuytren,  428,  396 

Gooch,  381 

Hammond,  389 

Hodgen,  418 

interdental,  389 

Jones'  cock-up,  408 

Kingsley's  interdental, '390 

Levis,  407 

Mclntyre,  418 

Matas,  390 

Moriarty's,  389 

Plaster  of  Paris,  89 

pressure,   causing  gangrene,  381,  131 

Roberts,  407 

Smith.  418 

Stromeyer,  402 

Thomas,  415,  380 

triangle,  397 
knee,  487 

Van  Arsdale,  420 
Splintered  fracture,  374 
Splints,  plastic,  381 
Splitting  fracture  of  skull,  516 
Spondylitis,  557 

deformans,  557,  489 
Spondylolisthesis,  557 
Spondylosis  rhizomelique,  489 
Sponges,  preparation  and  sterilization  of, 

62 
Spontaneous  aneurysm,  296 

dislocation,  453 

fracture,  374 


Spontaneous  gangrene,  128 

hemorrhage,  306,  519 

hemostasis,  305 
Spores,  42 

Sporothrix  Schcnckii,  246 
Sporotrichosis,  246,  51 
Sporulation,  42 
Sprains  of  joints,  452 
Sprengel's  deformity,  975 
Springing  hip,  988 
Spurious  meningocele,  501 

valgus,  994 
Squamous  epithelioma,  217 
Square  cap  bandage,  81 
Ssbanejew-Franck   operation   for  gastros- 
tomy 711 
Stab  wounds,  144 
Stacke's   operation   for   mastoid   disease, 

568 
Stains,  gunpowder,  146 
Stamm-Kader  operation  of  gastrostomy, 

708 
St.  Anthony's  fire,  174 
Staphylococcic  infections,  42,  432,  613 
Staphylococcus  pyogenes,  albus,  106 

aureus,  247,  106 

cereus  albus,  107 
flavus,  107 

citreus,  106 

epidermidis  albus,  106,  141 

fiavescens,  107 
Staphylorrhaphy,  652 
Starch  bandages,  90,  76 
Starting  pains,  481,  484 
Static  machine,  14 
Status  lymphaticus,  341,  583 

presens,  2 
Stay  knot,  320 

Steel  plates  for  fixation  of  fractures,  381 
Steinmann's  nail  extension,  419 
Stellate  fracture,  374,  516 
Stellwag's  sign,  582 

Stellwagon's  instrument  for  making  trap- 
door in  skull,  509 
Steno's  duct,  affections  of,  642 
Stercoraceous  vomiting,  741,  9 
Stercoral  ulcers,  749 
Stereognostic  center,  506 
Stereoscopic  plates,  in  X-ray  diagnosis, 
17,  378 

localizing  foreign  bodies,  16,  17 
Sterility,  902,  957,  20 

due  to  X-ray  exposure,  20 
Sterilization,  51,  42 

after  operation,  69 


1076 


INDEX 


Sterilization,  chemical,  52,  149 

fractional,  60 

mechanical,  51,  148,  139 

of  bladder,  67 

of  Cargile  membrane,  63 

of  catgut,  60,  61 

of  catheters,  63 

of  cotton  goods,  63 

of  dressings,  62,  52 

of  ear,  67 

of  enamel  ware,  63 

of  glass,  63 

of  gloves,  64 

of  hands,  64 

of  hard  rubber,  63 

of  instruments,  63,  59 

of  leather,  63 

of  mouth,  65,  67 

of  normal  salt  solution,  63 

of  nose,  67 

of  oiled  silk,  63 

of  paraffin  paper,  63 

of  patient,  skin  of,  64 

of  rectum,  67 

of  rubber  tissue,  63 

of  silver  foil,  63 

of  soft  rubber,  63 

of  sutures  and  ligatures,  62 

of  syringes,  63 

of  vagina,  67 

of  water,  63 

of  wounds,  54,  139 

thermal,  51 
Sterilizer,  59 
Sternomastoid  in  torticollis,  573 

division  of,  562 
Sternum,  dislocation  of,  465 

fractures  of,  392 

necrosis  of,  393 
Stertorous  respiration,  513,  531 
Stewart's  enterostomy,  755,  756 

gastroenterostomy  method,  715 

gastrostomy,  708 

operation  for  cancer  of  the  breast, 
629 
for  inguinal  hernia,  808 

subtotal  gastrectomy,  728 
Sthenic  inflammation,  93 

fever,  167 
Stiles'  operation  for  hydrocephalus,  529 
Stiller's  sign,  739 

Stimson  and  Weir's  method  of  steriliza- 
tion of  hands,  64 
Stings  of  insects,  153 
Stitch  abscess,  73 


Stomach,  absorptive  power  of,  testing,  702 

affections  of,  688 

bilocular,  695 

carcinoma  of,  704 

congenital  stenosis  of  pylorus,  688 

dilatation  of,  699 

foreign  bodies  in,  689 

hourglass,  695 

injuries  to,  670 

lavage  of,  706 

operations  on,  706 

peristaltic  movements  of,  701 

prolapse,  702 

rupture  of,  670 

stenosis  of  pylorus,  688 

ulcer  of,  689,  690,  2 
perforation  of,  693 

volvulus  of,  703,  706 
Stomatitis,  647 

aphthous,  647 

gangrenous,  see  noma 

mercurial,  202 

ulcerative,  648 
Stone,  see  calculus 

forceps,  879 

scoop,  879 

sound,  877 
Stovain,  38 

Strabismus,  531,  534,  572 
Strains,  362 

Strangulated  hernia,  821,  132 
Strangulation  of  intestine  by  bands,  743 
Strauss,  pj'loroplasty,  725 
Strawberry  gall-bladder,  780 
Streptobacilli,  42 

Streptococcic  infections,  42,  432,  613 
Streptococcus  erysipelatis,  174,  231 

pyogenes,  174,  166 
Streptothricoses,  51 
Strep tothrix  madurse,  1S9 
Stretching,  in  scars,  105 

in  skin  surgery,  256 
Stricture,  see  special  regions 

from  gummata,  200 
Stromeyer  splint,  403 
Struma,  578 
Strumitis,  577 
Strumous,  208 

lip,  638 
Strj'chnin  poisoning,  9,  180 
Stumps,  amputation,  affections  of,  1006 
Stupe,  99 

Styloid  process,  fracture  of,  405 
Styptics,  310 
Subacromial  bursitis,  373,  975 


INDEX 


1077 


Subaponeurotic  abscess,  502 

hematoma,  500 

lipoma,  502 
Subastragaloid  amputation,  1017 

dislocation,  472 
Subclavian  artery,  compression  of,  313 
ligation  of,  325 

vein,  ligation  of,  572 

vessels,  injuries  of,  393 
Subclavicular     dislocation     of     shoulder, 

459 
Subconjunctival  ecchymosis,  572,  519 
Subcoracoid  dislocation  of  shoulder,  450 
Subcutaneous  injection  of  paraflSn,  586 

emphysema,  263 

hematoma,  500 

symptoms,  264 

treatment,  264 
Subdeltoid  bursa,  affection  of,  373,  975 
Subdural  abscess,  532,  533 

hemorrhage,  520,  551 
Subglenoid  dislocation  of  shoulder,  459 
Subhyoid  cysts,  572 

pharyngotomy,  605 
Subinfection,  46 
Subinvolution  of  uterus,  937 
Subjective  symptoms  in  diagnosis,  2 
Sublingual  dermoids,  572 
Subluxation,  455 

of  head  of  radius,  463 

of  humerus,  460 

of  knee,  471 
Submammary  abscess,  622 
Submaxillar}'    cellulitis,     see     angina 

Ludovici 
Subpericranial  hematoma,  500 
Subperiosteal  fracture,  374 

gummata,  438 

resection  of  joints,  495 

whitlow,  981 
Subphrenic  abscess,  6S4,  780 

locations  of,  684 
Subserous  lipoma,  see  lipoma 
Subspinous  dislocation  of  shoulder,  459 
Subsynovial  lipomata,  222 
Subtemporal  decompression,  512 
Subungual  exostosis,  225 
Suffusion,  138 
Sugillation,  138 
Sulcus,  intraparietal,  503 

precentral,  503 
Sun  baths  in  tuberculosis,  212 
Sunburn,  155 

Superficial  epithelioma,  251 
Superinvolution  of  uterus,  937 


Superior  gluteal  nerve,  affections  of,  360 

longitudinal    sinus,     thrombosis    of, 
5,Si,  532 

maxilla,  affections  of,  sec  upper  jaw 
fraction  of,  388 

maxillary  nerve,  resection  of,  351 

thyroid  artery,  ligation  of,  323,  581 
Supernumerary  digits,  978 
Supersensitiveness,  see  anaphylaxis,  50 
Suppression  of  urine,  847 
Suppuration,  106 

pathology  of,  107 

see  also  special  regions 
Suppurative  synovitis,  477 
Supracondyloid  amputation  of  thigh,  1021 

fracture  of  femur,  420 
humerus,  400,  401 
Supracoracoid  dislocation  of  humerus,  459 
Supramammary  abscess,  622 
Supramarginal  convolution,  504 
Suprameatal  triangle,  569 
Supraorbital  nerve,  operations  on,  351 
Suprapubic  aspiration  of  bladder,  871 

cystotomy,  879 

lithotomy,  879 

prostatectomy,  918 
Suprarenal  extract,  see  adrenalin,  583 
Supratrochlear    nerve,    operation    upon,. 

351 
Supravaginal  hysterectomy,  950 
Surgeon's  knot,  142 
Surgical  anesthesia,  21 

emphysema,  611 

kidney,  852 

scarlatina,  169 

technic,  59 
Suspension   and   extension   apparatus   of 

Blake,  399 
Suspensory  bandage,  84 
Suture  a  distance,  348 

of  blood  vessels,  315 

of  bone,  62 

of  heart,  172 
Suture-ligature,  314 
Sutures,  60,  149,  140 

see  also  special  regions 
Swallowing  in  anesthesia,  34 
Sweep's  cancer,  252 
Swelling  in  inflammation,  94 

in  tumors,  240,  241 
Swift-Ellis  treatment  of  syphilis,  204 
Sycosis,  X-ray  treatment,  18 
Sylvester's  artificial  respiration,  33 
Sylvius,  fissure  of,  503 
Symbiosis,  46,  178 


loyS 


INDEX 


Syme's  amputation,  1017 

external  urethrotomy,  804 

staff,  894 
Symmetrical  gangrene,  1 2g 
Symond's  tube  for  esophageal  stricture, 

662 
Sympathetic  ganglia,  cervical,  excision  of, 
361,  584,  537 

inflammation,  92 

nerve,  afJections  of,  360 
Symptomatic  hydrocele,  909 

fragilitas  ossium,  442 
Symptoms,  objective,  i 

subjective,  i 
Syncope,  163 

Syncytioma  malignum,  954,  219 
Syndactylism,  979 
Syndesmotomy,  993 
Synechia,  595 
Synorchism,  902 
Synovial  inflammation,  in  diagnosis,  7 

membrane,    pulpy    degeneration    of, 

479 
Synovitis,  acute,  475 
chronic,  477 
gonorrheal,  473 
gummatous,  478,  19S 
lipomatosis,  222 
pj'cmic,  477 
rheumatic,  476 
serous,  475 
sj^philitic,  473,  198 
tuberculous,  see  joints 
typhoid,  473 
Syphilides,  197,  196 
pigmentary,  198 
tubercular,  198 
Syphilis,  191,  51 
acquired,  191 
chancre,  192 
conceptional,  191 

congenital  or  hereditary,  206,  207,  191 
immunity  in,  191 

CoUes,  192 

Profetas,  192 
incubation  period,  192 
insonitum,  191 
methods  of  injection,  igi 
prognosis,  200 
quarternary,  200 
stages,  192 

intermediate,  199 

primary,  see  chancre 

secondary,  196 
alopecia  in,  198 


Syphilis,  stages,  secondary,  condylomata, 
198 
fever  of  eruption  196 
lymphatic  involvement,  196 
mucous  patches,  198 
skin  rashes,  198 
syphilides,  198 
tertiary,  199 

diagnosis  of,  200 
diffuse  sclerosis,  199 
gumma,  199 
syphilides  in,  199 
treatment,  201 
continuous,  201 
fumigation,  201 
intermittent,  201 
intramuscular,  201 
intravenous,  201 
inunctions,  201 
local,  206 
mixed,  203 
neosalvarsan,  205 
salvarsan,  203 
serum,  201 

see  also  special  regions 
Swift-Ellis  method,  204 
Syphilitic  arteritis,  291,  480 
bubo,  193 
fever,  196 
lichen,  197 
S3'philodermata,  see  syphilides 
Syringes,  sterilization  of,  62 
Syringomyelia,  joint  affections  in,  4S9 
Syringomyelocele,  552 

T-bandage  of  perineum,  86 
T-fracture,  374,  400 
Tachycardia,  583 
Tailed  bandage,  78,  86 
Talipes,  991 

acquired,  992 
decubitus,  992 
paralytic,  992 
spastic,  992 
traumatic,  992 
calcaneus,  140,  994 
congenital,  991 
equinus,  140,  994 

varus,  992 
valgus,  140,  994 
varus,  140,  994 
Talma's  operation,  777 
Tamponage  of  heart,  274 
Tampons,  vaginal,  958 
Tampotement,  98 


INDEX 


1079 


Tangenital  wounds  of  brain,  523 
Tapping,  sec  special  regions 
Tarsectomy,  99.? 
Tarsometatarsal    joints,    amputation 

through,  1015 
Tarsus,  amputation  througli,  ioi() 
dislocation  of,  47,^ 
fracture  of,  430 
tul)erculous  disease  of,  486 
Taxis,  S.M 
Teale's  amputation  of  leg,  1018 

probe  gorget,  895 
Technic  of  modern  surgery,  59 

-see  also  special  regions 
Teeth,  carious,  338,  598 
Hutchinson,  207 
in  congenital  syphilis,  207,  5 
in  rickets,  440 

tumors  in  connection  with,  see  odon- 
toma 
Telangiectatic  angioma,  226 

sarcoma,  230 
Temperature,  local,  in  diagnosis,  9 
Temporal  artery,  compression  of,  313 

ligation  of,  324 
Temporary  hemostasis,  139 
Temporomaxillary  joint,  ankylosis  of,  650 
joint,  arthritis,  suppurative,  568 
dislocation  of,  457 
excision  of,  651 
Temporosphenoidal  abscess,  533 
Tenderness  in  abdominal  affections,  691 

in  diagnosis,  8 
Tendo-Achillis,  synovitis  of,  998 

tenotomy  of,  366,  419 
Tendon  sheaths,  diseases  of,  366 
Tendons,  affections  of,  362 
displacement  of,  363 
lengthening  of,  369 
operations  on,  366 
rupture  of,  362 
shortening  of,  370 
subluxation,  364 
suppurative,  365 
transplantation  of,  370,  994 
Tenesmus,  7 
Tenia  barbae,  18 

echinococcus,  233 
saginata,  235 
solium,  235 

tonsuranus,  treatment  with  Rontgen 
rays,  18 
Tennis  leg,  991 
Tenoplasty,  368 
Tenorrhaphy,  367,  368J 


Tenosynovitis,  365 
suppurative,  983 
tuberculous,  365 
Tenotomy,  366,  993 

see  also  individual  tendons 
Tenth  nerve,  affections  of,  354 
Tents  for  dilatation  of  os  uteri,  932 
Teratomata,  232,  215 

of  sacrum,  553 
Tertiary  syphilis,  191 
Testis,  affections  of,  902,  8 
atrophy  of,  90S,  903 
congenital  malformation  of,  902 
cysts  of,  907 
ectopic,  903 
fungus  of,  906 
hematocele  of,  912 
hernia  of,  907 
hydrocele  of,  911 
inflammation,  905 
inversion,  902 
malposition  of,  902 
neuralgia  of,  909 
retained,  902 
sclerosis  of,  198 
syphilis  of,  906 
torsion  of,  904 
tuberculosis  of,  905 
tumors  of,  907 
undescended,  902,  806 
Tetanolysin,  179 
Tetanospasmin,  179 
Tetanotoxin,  179 
Tetanus,  178,  181,  46 
acute,  179 
cause,  178 
chronic,  179 
hydrophobicus,  180 
idiopathic,  178 
late,  180 
local,  180 
neonatorum,  180 
paralyticus,  180 
prophylaxis,  181 
risus  sardonicus  of,  179,  9 
treatment,  18 1 
Tetany,  180,  46 

parathyreopriva,  576 
Tetracocci,  42 
Thecal  whitlow,  982 
Thecitis,  365 

suppurative,  982,  983 
Therapeutic  effects  of  the  X-ray,  19 
Thermal  injuries,  155 
sterilization,  51  j 


I060 


INDEX 


Thiersch's  method  of  skin  grafting,   260 

operation  for  epispadias,  882 
Thigh,  amputation  of,  1022 
Third  nerve,  affections  of,  349 
Thomas's  incision  for  capsulotomy,  461 
knee  splint,  487 
splint,  380,  379,  485 
wrench,  993 
Thoracic  duct,  ligation  of,  335 
obstruction  of,  9 
wounds  of,  335 
Thoracoplasty,  616 
Thoracotomy,  615 
Thorax,  surgery  of,  609 
Thorium,  20 
Thrill,  8 
Throat  cut,  575 
Thromboangitis  obliterans,  128 
Thrombophlebitis,  277,  248,  280 
Thrombosis,  265,  277,  597 
arterial,  290 
changes  in,  266 
gangrene  from,  290,  131 
localization,  266 
of  cerebral  sinuses,  531 
cavernous  sinus,  532 
lateral  sinus,  531,  534,  169 
mesenteric  vessels,  687 
petrosal  sinus,  532 
superior  longitudinal  sinus,  531 
results,  266 
types,  265 
venous,  266 
Thrush,  647,  51 
Thumb,  amputation  of,  1008 
dislocation  of,  464,  465 
fracture  of,  409 
Thymic  asthma,  584 

stenosis  of  trachea,  584 
Thymus  gland,  enlargement  of,  341,  584 
Thyroglossal  cyst,  571 

fistula,  570 
Thyroid  cysts,  577 

dislocation  of  hip,  469,  466 
extract,  580 
gland,  accessory,  576 
absence,  577 
actinomycosis,  577 
atrophy,  577 
congestion,  577 
tumors  of,  577 
vessels,  ligation  of,  580 
wounds,  576 
Thyroidectomy,  580,  581 
Thyroidism,  580 


Thyroiditis,  577 
Thyrotomy,  604;  605 
Tibia,  fracture  of,  424 

epiphyseal  separation  of  lower  end, 

425 
of  upper  end,  425 

fracture  of  424 

internal  malleolus,  425 
shaft,  425 
tubercle,  424 
upper  end, 424 

osteotomy  of,  991 

rachitic,  991 

syphilitic,  991 
Tibial  arteries,  see  anterior  and  posterior 
Tibialis  anticus,  tenotomy  of,  366 

posticus,  tenotomy  of,  367 
Tic  convulsif,  350 

douloureux,  350 

facial,  350 
Tinnitus  aurium,  307 
Tissue,  repair  of,  loi 
Tissues,  consistency  of  in  diagnosis,  7 
Toe-nail,  ingrowing,  255 
Toes,  amputation  of,  1014 

deformities  of,  998 

dislocation  of,  473 
Tongue,  affections  of,  642 

abscess  of,  643 

actinomycosis,  644 

cancer  of,  646 

chancre  of,  645 

epithelioma  of,  645 

gumma  of,  645 

lupus,  644 

removal  of,  646 

syphilis,  645 

tie,  642 

ulceration  of,  644,  19& 
tuberculous,  196,  645 

wounds,  643 
Tonsiliotome,  655 
Tonsillotomy,  654 
Tonsils,  affections  of,  654 

enucleation  of,  654 

hypertrophy,  654 

suppuration,  654 

tumors,  655 
Tophi,  487,  372 

Topography,  craniocerebral,  502 
Torsion  fracture,  375 

in  treatment  of  hemorrhage,  314,  70 

of  omentum,  686 

of  ovarian  cyst,  968 

of  spermatic  cord,  904 


INDEX 


I081 


Torticollis,  572 

false,  572 

true  or  chronic,  572 
permanent,  573 
spasmodic,  572 
Total  empyema,  613 
Tourniquets,  312 
Toxalbumins,  45 
Toxemia,  45,  166 
Toxins,  45 
Toxophore,  49 
Trachea,  cicatrices  in,  599 

diseases  of,  599 

foreign  bodies  in,  599 

intussusception  of,  599 

rupture  of,  610 

stenosis  of,  599 

tumors  of,  604 

ulceration  of,  608 

wounds  of,  575 
Trachelorrhaphy,  933 
Tracheocele,  571 
Tracheotomy,  606,  32 

high,  606 

low,  607 

preliminary,  606 

tubes,  607 
Trachoma,  209 
Transfusion  of  blood,  285 
Transhyoid  pharyngotomy,  605 
Transient  obstruction  of   bile   duct,    787 
Transillumination  of  antrum,  596 

stomach,  702 
Transplantation    of    mucous    membrane, 
263 

of  bone,  449,  382 
flap  method,  450 
free  method,  450 

of  cartilage,  451 
Transverse  fracture,  374 
Transversotomy,  755 
Traumatic  aneurj^sm,  293,  296 

apoplexy,  519 

arteritis,  292 

asphj^xia,  610 

delirium,  173 

dermoid,  233 

diabetes,  166 

dislocations,  455,  456 

epilepsy,  537 

fever,  166 

fracture,  374 

gangrene,  132,  133 

hemorrhage,  306,  519 

hernia,  778,  791,  804 


Traumatic  hysteria,  547 
inflammation,  93 
insanity,  538 
meningocele,  501 
myositis,  364 
neurasthenia,  547 
neuritis,  347 
neuroses,  546 
spreading  gangrene,  134 
ulcers,  116 
Trench  foot,  160 

Trendelenburg's  varicose  veins,  283 
position,  950 
test    for    valvular    incompetence    in 

varicose  veins,  281 
tracheal  tampon,  605 
Trephining,  507 

for  epilepsy,  538 

fracture  of  skull,  517 
insanity,  538 
intracranial  abscess,  535 
intrameningeal  hemorrhage,  520 
inveterate  headache,  538 
lateral  sinus  thrombosis,  531 
meningitis,  531 
for    middle    meningeal   hemorrhage, 
520,  507 
puncture  of  lateral  ventricle,  529 
tumors  of  brain,  537 
Treponema  pallida,  191 
Treves'  operation  for  lumbar  caries,  563 
Triangle  of  election,  321 
of  necessity,  321,  322 
splint,  397 
Trichiniasis,  364,  13 
Trident  hand,  442 
Trifacial  nerve,  affections  of,  350 

neuralgia,  350 
Trigeminal  nerve,  350 
Trigger  finger,  979 
Tripod,  Sayre's,  562 
Tripolith  bandage,  89 
Tripperfaden,  886 
Trismus,  180,  179,  651 

nascentium,  180 
Trochanter,  bursa,  373 

fracture  of,  415,  416 
Tropacocain,  38 
Trophic  gangrene,  132 

changes  following  section  of  nerves, 
346 
True  keloid,  249,  220 

neuromata,  343 
Trusses,  806,  807 

see  special  herniae 


io82 


INDEX 


Trypanosomiasis,  51 
Tubal  abortion,  961 
gestation,  961 
rupture  of,  '961 
Tube,  Crooke's,  14 
Tubercle,  209 

anatomical,  250 
bacilli,  see  bacillus 
Tuberculin,  211,  50 
dose,  212 
Koch's,  213 
new  (T.  R.),  212 
old,  212 
test,  210 
Tuberculocidin,  213 
Tuberculosis,  208 
diagnosis,  210 
etiology,  209 
gummata,  250 
iodoform  in,  55 
mode  of  extension,  210 
prognosis,  211 
treatment,  211 
ulcerosa,  250 

see  also  special  regions 
Tuberculous  diathesis,  208 

gummata,  250 
Tuber  ischii  bursitis,  373 
Tubes,  Fallopian,  disease  of,  957 
Tubo-ovarian  cysts,  967 
Tubular  adenoma,  216 
lymphangitis,  337 
Tubulated  aneurysm,  296 
Tubulo-dermoids,  233 
Tufnell's  treatment  of  aneurysm,  300 
Tumors,  214,  235,  215 

see  also  various  regions 
consistency  of,  240 
diagnosis  of,  235 
margins  of,  in  diagnosis,  239 
Tunica  vaginalis,  hydrocele  of,  911 
Turpentine  stupe,  54 
Tuttle's  sigmoidoscope,  826 
Twelfth  nerve,  injuries  of,  354 
Twisted  suture,  141 
T\^mpanum,  rupture  of,  518 
Typhlatomy,  736 
Typhlectasia,  736 
Typhlospasm,  736 
Typhoid  arthritis,  478 
bacillus,  see  bacillus 

in  gall-bladder,  434 
osteomyelitis,  433,  434 
spine,  557 
state,  168 


Typhoid  ulcer,  perforation  of,  437 
Widal  reaction,  14,  48 

Ulceration,  116 

see  also  special  regions 

herpetic,  195 

in  scars,  105 

in  tumor  diagnosis,  243 
Ulcerative  appendicitis,  767 

ulcerosa  tuberculosis,  250 
Ulcere  des  phthisiques,  250 
Ulcers,  acute,  121,  118 

bone,  437 

callous,  122 

carcinomatous,  118 

chancroid,  896,  193 

chronic,  122 

Curling's,  156 

diagnosis  of,  117 

discharge,  119 

dyspeptic,  644 

eczematous,  122 

edges,  118 

embolic,  116 

epitheliomatous,  see  epithelioma 

erethistic,  122,  116 

floor  of,  118 

following  Rontgen-ray  burns,  19 

gastric,  690 

glandular  involvement,  118 

gummatous,  199 

healing,  123,  118 

indolent,  122,  118 

inflamed,  119 

irritable,  122 

lupoid,  250,  118 

malignant,  116 

Marjolin's,  218 

neuralgic,  122,  116 

of  anthrax,  116 

of  benign  tumors,  243 

of  congenital  syphilis,  206 

of  glanders,  116 

of  leprosy,  116 

pathology  of,  116 

peptic,  690 

perforating,  of  sole  of  foot,  116,  999 

phagedenic,  116 

pressure,  117 

pyogenic,  116 

rodent,  251,  18 

scirrhous,  626 

scorbutic,  ii8 

serpiginous,  199 

simple,  116 


INDEX 


1083 


Ulcers,  specific,  116 
stercoral,  749 
syphilitic,  118,  193 
traumatic,  iiS 
treatment  of,  119 
trophic,  118 

tuberculous,  250,  196,  118,  250 
typhoid,  737 
varicose,  282,  118,  116 

see  also  special  regions 
Ulna,  dislocation  of,  463,  464 
fracture  of,  404 

coronoid  process,  405 
olecranon,  404 
radius  and  ulna,  408 
shaft,  405 

styloid  process,  405 
Ulnar  artery,  compression  of,  313 
ligation  of,  328 
nerve,  dislocation  of,  358 
injury  of,  358,  404 
Umbilical  fistula,  677 
hernia,  814 
adult,  81S 

congenital  or  exomphalos,  814 
infantile,  814 
sinuses,  678 
Umbilicus,  affections  of,  677 
Unconsciousness,  514,  5^9 
diagnosis,  514 
varieties,  519 
Undescended  testis,  902 
Ungual  whitlow,  254 
Union  of  fractures,  385 

wounds,  103 
Unna's  paste,  122 

treatment  of  ulcers,  125 
Unreduced  dislocation,  457 
Ununited  fractures,  385 
Upper  common  duct,  stone  in,  787 
digestive  apparatus,  634 
extremity,  deformities  of,  977 
jaw,  see  jaw 
Urachal  cysts,  677,  233 
Uranium,  20 
Uranoplasty,  653 
Uremia,  515,  534 
Ureteral  anastomosis,  865 
bougie,  858 
calculus,  857 
caruncle,  922 
fistulae,  848,  929 
Ureteritis,  854 
Ureters,  calculus  in,  857 

catheterization  of,  843,  868 


Ureters,  exploration  of,  863 
hemorrhage  from,  846 
ligation  of,  848 
operation  on,  862 
rupture  of,  674 
wounds  of,  848 
Ureterocystostomy,  866 
Ureteroenterostomy,  864,  866 
Ureterolithotomy,  865 
Ureteropyelostomy,  865,  866 
Ureterostomy,  864,  866 
Uretero  uterine  fistula,  927 

vaginal  fistula,  927 
Urethra,  abscess  of,  889 
affections  of,  882 
calculus,  impacted  in,  885 
caruncles,  922 
chancre,  195 
chancroid,  897 

congenital  malformation  of,  882 
absence,  882 
epispadius,  882 
hypospadius,  883 
narrow  meatus,  882 
occlusion,  882 
stricture,  882 
contusions  of,  884 
false  passage  of,  895 
folliculitis  of,  889 
foreign  bodies  in,  884 
hemorrhage  from,  847 
irrigation  of,  888 
rupture  of,  884 
stricture  of,  890 

dilatation  of,  891 
symptoms,  891 
treatment,  892 
dilatation,  893 
urethrectomy,  895 
urethrotomy,  893 
varieties,  890 
Urethral  bougies,  892 
fever,  895 
syringe,  889 
Urethrectomy,  895 
Urethritis,  885 
simple,  885 

specific  or  gonorrheal,  885 
Urethrorrhea,  889 
Urethroscope,  889 
Urethrotome,  893 
Urethrotomy,  external,  893 

internal,  893 
Urethrovaginal  fistulae,  927 
Urinary  fever,  895 


1084 


INDEX 


Urinary  fistula,  890,  927,  678 

organs,  diseases  of,   843 
Urination,  spontaneous,  71 
Urine,  extravasation  of,  884 

incontinence  of,  869 

in  septicemia,  168 

pus  in,  846 

residual,  917,  871 

retention  of,  870,  71 
incontinence  of,  869 

suppression  of,  847 
Uronephrosis,  850 
Urticaria,  gangrenous,  248 
Uterine  colic,  956 

sound, 921 
Uterus,  abscess  of  wall,  935 

affections  of,  930 

amputation  of  cervix,  932 

atrophy  of,  937,  930 

carcinoma  of,  952 
varieties,  952 

congenital  malformations,  930 
atrophy,  930 
bicornis,  930 
bipartitus,  931 
didelphis,  930 
infantile,  930 
Uterus,  congenital  unicornis,  931 

curettage  of,  949 

deciduoma  malignum,  954,  219 

dilatation  of  cervix,  931 

dislocation  of,  938 

displacements  of,  937 

erosion  of  cervix,  933 

eversion  of  cervix,  933 

fibroids  of,  947 
varieties,  947 

h>'pertrophy  of  cervix,  932 

inflammation  of,  937 

inversion  of,  945,  946 

laceration  of  cervix,  933 

morcellement  of,  949 

myoma  of,  947 

polypi  of,  947,  951 

prolapse  of,  943 

reposition  of,  940 

sarcoma  of,  952 

septus,  930 

stenosis  of  cervix,  931 

subinvolution  of,  937 

superinvolution  of,  937 

syncytioma  malignum,  954,  219 

tumors  of,  947,  951 

ulceration  of  cervix,  934 
Uvula,  elongation  of,  654 


V-shaped  fracture,  374 

incision,  256 
Vaccin,  50 
Vaccination,  184 
Vacquez's  disease,  798 
Vagina,  affections  of,  922 

atresia,  923 

cysts  of,  930 

injuries,  923 

stenosis,  923 

sterilization  of,  68  / 

Vaginal  enucleation  of  fibroids,  949 

fistula,  927 

hematocele,  912 

hernia,  817,  803 

hydrocele,  909 

hysterectomy,  949,  953 

speculae,  919 
Vaginalitis,  serous,  909 
Vaginismus,  930 
Vaginitis,  929,  930 
Valentine's  urethroscope,  889 
Valgus,  acquired,  995 
Van  Arsdale's  splint,  420 
Vanghetti's  operation,  ion 
Van  Hook's  operation  for  ureteral  anasto- 
mosis, 865 
Vaporizing  apparatus  for  anesthesia,  25,  26 
Varicocele,  912,  806,  973 
Varicose  aneurysm,  305 

ulcers,  282,  116 

vein,  choice  of  operation,  284 

veins,  279 
Variola,  51 
Varix,  279 

aneurysmal,  304 

arterial,  294,  226 

causes,  279 

complications,  282 

eczema,  282 

excision  of,  283 

lymphangitis,  281 

pathology  of,  280 

rupture,  282 

symptoms,  281 

thrombophlebitis,  280,  282 

treatment,  282 

ulceration,  282 
Vascular  goiter,  579 

tumor,  243 
Vas  deferens,  anastomosis  of,  912 

ligation  of,  for  recurring  epididymitis, 

905 
rupture  of,  912 
tuberculous  disease  of,  905 


INDEX 


1085 


Vasotribc,  314 

Veins,  affections  of,  277 

canalization  of,  265 

contusions,  289 

entrance  of  air  into,  270 

ligation  of,  314 

transplantation  of,  289 

varicose,  279 

wounds  of,  289 
Velpeau's  bandage,  84,  394 
Venereal  warts,  897,  216 
Venesection,  284,  i^,  it 2 
Venous  hemorrhage,  306 

nevus,  226 

obstruction,  5,  6 

sinuses,  thrombosis  of,  531 

thrombosis,  266 

wounds,  289 
Ventral  hernia,  816 

suspension,  942 
Ventriculography,  527 
Ventrofixation,  942 
Vermiform  appendix,  765 
Veronal  in  anesthesia,  28 
Verruca,  249,  250 
Vertebra;,  see  spine 
Vertebral  artery,  compression  of,  313 

ligation  of,  326,  537 
Vertical  sulcus,  503 

traction  in  fracture  of  femur,  421 
Vertico-mental  triangle,  81 
Vesical  calculus,  876 

hematuria,  846,  876 
Vesicouterine  fistula,  927 
Vesicovaginal  fistula,  927 
Vesiculse  seminales,  affections  of,  913 
Vesiculitis,  913 
Vibrios,  43 

Vicarious  menstruation,  955,  592,  694 
Vicious  union  of  fractures,  386 

circle  after  gastroenterostomy,  711 
Villous  tumor  of  bladder,  see  papilloma 

warts,  216 
Virchow's  law,  214 
Virus,  50,  182 

fixe,  184 
Viscera,  injuries  of,  670 
Volkmann's  contracture,  976,  364 

operation  for  hydrocele,  911 
Volsella  forceps,  920 
Volvulus,  of  intestine,  745 

cecum  or  ascending  colon,  745 

omentum,  686 

sigmoid  flexure,  745 

stomach,  703,  706 


Vomiting,  cerebral,  535 
continued,  72 

persistent  in  anesthesia,  34,  35 
stercoraceous,  741 

see  also  special  conditions 
Von  Bergmann's  operation  for  hydrocele, 

911 
treatment  of  gastric  ulcer,  692 
Von    Eiselberg's    unilateral    exclusion    of 

pylorus,  724 
Von  Esmarch's  tourniquet,  312 
Von  Graefe's  sign,  582 
Von  Hacker's  method  of  gastro-enteros- 

tomy,  713 
Von  Jaksch's  disease,  798 
Von  Pirquet's  tuberculin  test,  211 
Von  Recklinghausen's  ostitis  fibrosa,  445 
Vulpius,  tenorrhaphy,  368,  370 
Vulva,  affections  of,  921 
Vulvitis,  921 
Vulvovaginal  gland,  abscess  of,  922 

Wallerian  degeneration,  347 
Wardrop's  operation  for  aneurysm,  303 
Wart  horn,  249 
Warts,  249,  215 

anatomical,  249 

lymphatic,  335 

soot,  252 

venereal,  897,  216 
Wassermann  serum  reaction  for  syphilis, 
197 

test  for  chancre,  194  ' 
Water  bed,  548 

glass   bandage,   see   silicate   of   soda 

sterilization,  63 
Watkin's  operation,  945,  927 
Watson's  double  nephrostomy,  864 
Wax,  Horsley's,  510 

in  ear,  566 

Moorhof's,  437 
Waxy  degeneration,  113 
Weaver's  bottom,  373 
Webbed  fingers,  979 
Wedge  fracture  of  skull,  516 
Weight,  in  diagnosis,  10 
Weir's  appendicostomj^,  773 

operation  for  hallux  valgus,  997 

resection  of  the  rectum,  842 
Wen,  254,  232 
Wertheim's  operation,  945 
Wet  drip,  97 

Wheelhouse's    operation    for    impassable 
stricture,  894 

staff,  894 


io86 


INDEX 


White  patches,  in  diagnosis,  6 
infarct,  268 
swelling,  112,  480,  486 
thrombus,  265 
Whitehead's  operation   for   hemorrhoids, 
836 
on  tongue,  646 
varnish,  647 
White's    operation    for    excision   of   hip, 

497 
Whitlow,  981,  194 

thecal,  982 

ungual,  254 
Widal,  agglutination  reaction,  14 

reaction,  47,  14 

in  sporotrichosis,  246 
Will,  center  of,  506 
Willem's  drainage  of  joints,  452 

treatment,  suppurative  arthritis,  479 
Wilm's  operation  for  cecum  mobile,  737 

treatment  of  gastric  ulcer,  692 
Wire,  aluminium  bronze,  62 

iron,  62 

silver,  62 
Withering  scirrhus,  218,  627 
Witzel's  method  of  gastrostomy,  708 
Wolf's  method  of  skin  grafting,  260 
Wolfler's    method    of  gastroenterostomy, 

711 
Wooden  phlegmon,  575 
Wool-sorter's  disease,  185 
Word  deafness,  506 
Wounds,  138 

contused,  143 

disinfection  of,  139 

dissection  and  post-mortem,  152 

drainage,  71 

dressings,  71 

gunshot,  144 

incised,  142 

insect  stings,  153 

lacerated,  143 

military,  146 


Wounds,  poisoned,  152 

puncture  and  stab,  144 
repair,  103 
snake  bite,  153 
special  infections,  163 
treatment,  148,  145,  144,  142 
see  also  special  regions 
Wright's  solution,  151 
Wrist  drop,  357 

joint,  amputation  at,  1009 
dislocation  at,  464 
effusion  into,  478 
excision  of,  496 
gonorrheal  infection  of,  479 
tuberculous  disease  of,  482 
Wry  neck,  572 

Wyeth's   method    of    controlling   hemor- 
rhage in  amputation  at  hip,  1023 
at  shoulder,  1012 

X-ray,  14 

see  Rontgen  ray 

as  an  anodyne,  19 

burn,  19,  252 

Coolidge  tube,  15 

destructive  action  of,  18 

filters,  19 

gangrene,  134 

interpretation  of  pictures,  15 

therapeutic  effects  of,  18 
Xanthoma,  222 
Xeroderma  pigmentosum,  252 

Yeasts,  51 

Yellow  tubercle,  209 
Yellowish  discoloration  in  diagnosis,  5 
Y-fracture,  400 

Young's   method    of   perineal   prostatec- 
tomy, 918 

Zooglea,  42 

Zygoma,  fracture  of,  388 

Zymogenic  bacteria,  44 


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